Sunday, September 23, 2007

Drugs, doctors and education

The pharmaceutical scenario in our country [India] can be described as an ocean full of fish of which only a few are edible. The medical profession can be compared to a skillful swimmer who knows which of these are edible but will not always make his patient eat these. The patients are those who are ignorant of the ocean and the fish and keep eating inedible or useless fish because they don’t know the difference.

There exist a huge quantity and number of worthless or drugs in the market and most of them sell. The famous or as some wont to say infamous Haathi committee which recommended many years ago, one hundred odd drugs as essential for the practice of modern medicine has been given a descent burial as is the fate of most of such honest reports in our country.

One estimate is that there are more than10, 000 drug formulations in the market and more than 1000 drug companies peddling these! I may not be very accurate in my figures but they will give you a general idea how many players are involved and what a powerful lobby they constitute.

Let us now consider the common problems faced by our people. Anaemias with or with out vitamin deficiencies, infectious diseases of all types, diseases like high blood pressure, diabetes, heart disease, asthma, cancers, various pains and aches form most of these. All these can be adequately managed with drugs mentioned in the recommendations of the expert committee mentioned above. Let us take one example that of tonics. I don’t know how this word came into common usage by the patients, industry and the profession, but on this one word depends a multi billion rupee industry. Tonic is something that is supposed to pep you up or will make you feel stronger and it is a common experience with doctors to be asked by a patient to prescribe a tonic or give one. Will our friend the doctor say that there is no such a thing as a tonic that gives the patient strength and risk losing a patient? No fears, most professionals, with honorable exceptions, oblige the patient with one.

I must recount a personal experience here, years ago on a visit to my grand uncle I found him taking two spoonfuls of a famous brand of one such use less tonic daily. Knowing that he could ill afford such wasteful expenditure I felt compelled to tell him so. He told me off and said in no uncertain terms the efficacy of this tonic and that he owed his longevity to the continuous consumption of this over 40 years. The old man is no more but the brand is still alive and healthy and millions of Indians must be swearing by it!.

If these are medicinally useless then why patients take them? When they say they feel better are they lying? Sadly no. In medical parlance there is a term called placebo. Placebo is something that you give will result in some benefit even though it contains nothing aimed at such a benefit. The profession and the industry are dependent more on this placebo value of most of the formulations than the real drug content.

It is known that, that wonderful organ brain produces substances called endorphins that are literally like morphine in their chemical structure. Morphine is an opioid derived from poppy plant and has pain relieving and pleasure giving properties. Endorphins do the same. If given by doctor to a believing patient with a strong suggestion that he will be OK, the brain will release these endorphins and the patient will feel better. But the same result can be achieved by giving coloured salted or sugared water at a fraction of the cost! Only the patient should not know, and then he may not produce any endorphins!

Treating many of the major health problems of the nation is not difficult. Let me take two examples to illustrate my point. Hook worm infestation and the resulting anemia are responsible for lot of ill health especially in rural India. To eradicate the worms will take single dose of a wormicide and daily tablets of iron for two to three months. The cost of whole treatment for three months will be less than 100 rupees. I regret to say that usually the patient ends up paying much more than this because of his faith in tonics and doctors not educating the patients. Not long ago two drugs were available which were cheap and effective against iron deficiency anemia. One was called ferocelate, which contained enough of iron, and 100 pills would cost less than 5Rs and number of doctors used this with benefit on the poor patients. Today this brand which was selling well was bought over by another company and is being sold 20 times the cost. Another useful formulation was called macrafolin iron B12 this was also available around 10 Rs for 100 tablets. Today it is no longer available in the market. These two examples are sufficient to illustrate the social responsibilities of our leading pharma companies. Where as there are hundreds of compounds attractively packed containing the same iron and vitamin selling at exorbitant rates. Doctors prescribe, pharma companies sell and the poor sucker of a patient is forced to buy.

This brings me to the relationship that exists between pharma companies and the medical profession. With few honorable exceptions this is a perfect example of you scratch my back and I will yours. Doctors who don’t prescribe or dispense don’t impress the patient. The patient is like the devotee who goes to the temple and expects the priest to give him some thing as tokes of god’s good will. It may be some thing to eat or drink or it may be an offering of a flower. So is with the doctor. A patient will not like to return empty handed after consulting the doctor. On this single fact of patient psychology a whole industry of worthless drugs has been built up.

Pharma companies adopt the latest selling gimmickry to entice the doctors to prescribe. They send their representatives to visit, shower the doctor with gifts organize dinner/cocktail events with the ostensible purpose of introducing new products and even paying a leading or important doctors, travel [holiday?] expenses. What about doctors? Do they, who are supposed to belong to an exalted profession, respond to these overtures? I have hardly come across any one who refuses these goodies.

Doctors have to be educated and continually have to update their knowledge and skills. They will have to attend continuing medical education classes every now and then. Who pays to organize these? You think doctors pay for their education? Have no such illusions. It is usually the pharma companies who pick up the tab. occasionally medical organizations do attempt and charge a registration fee but this is enough to cover only part of the expenditure.

At present a sorry state of affairs exists. Even good [ethical] doctors are dependent on sponsorship to get educated! It is a shame that a simple luncheon meeting or a tea meeting attracts a small number where as a cocktails and dinner [education] evening will attract a huge number of hungry and thirsty doctors. You normally don’t bite the hand that feeds you. And the doctors who attend these meetings [eatings as I call them] end up prescribing the product. Here I must hasten to add that not always the promotion is for a worthless product.

Can't then doctors organize programs with out the help of these companies? Of course they can but it will mean spending money and when there is some one else to do this, which fool likes to? They have so gotten used to getting sponsorship it has become difficult to organize any meeting with out the help from one or other of these companies.

There are few doctors who can with stand this pressure. On the one hand from patients who clamour for drugs and on the other this kind of salesmanship by the drug manufacturers. The result is a sea of drugs in which the doctor and the pharma companies enjoy their swim and the poor patient drowns.


Robert Trent Jones, popularly known as Bobby Jones was an all time great golfer. His playing carreer was cut short because of Syringomyelia which left him crippled. At the 1971 Augusta national, an old friend met him and couldnot hold back his tears. Bobby told him,' now, now, we won't have that, we are supposed to play the ball as we find it'
An inherent part of any sport is a set of virtues that mirrors all the qualities desirable in the society. Integrity,honour, respect, rules and discipline, to name a few.


G.D. said...

I fully agree with your views on this. But it is a losing game for anyone who tries to take it head on knowing the kind of patients we have to deal with.There is an old saying- "When your patient wants an injection, you better give it or else your neighbour will give it to him?!" However many points are worthy of serious though by all concerned.

Unknown said...

A couple of years back I read a book by John Le Carre called the Constant Gardener. It very effectively, though chillingly conveys the power wielded by the pharma companies. It would make an interesting reading.
A similar recent one on genome technology(?) is by Michael Crichton, called Next.