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| An educational initiative looks critically at the drug industry's promotional
tactics
Bishnu Rath Giri, P. Ravi Shankar*
Bishnu Rath Giri is a sixth-semester medical student, and P. Ravi Shankar is
Assistant Professor of Pharmacology, at Manipal college of Medical Sciences,
Pokhara, Nepal.
Competing Interests: The authors declare that they have no competing interests.
Published: August 30, 2005
DOI: 10.1371/journal.pmed.0020256
Copyright: © 2005 Giri and Shankar. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Abbreviation: MR, medical representative
Citation: Giri BR, Shankar PR (2005) Learning How Drug Companies Promote
Medicines in Nepal. PLoS Med 2(8): e256
*To whom correspondence should be addressed: E-mail: pathiyilravi@gmail.com
Armed with the power to prescribe, doctors are in a position to flood their
patients' bodies with potent medicines at a stroke of their pen—and they have
been consistently wooed by the pharmaceutical industry.
Doctors in Nepal have started to become targets for the pharmaceutical
industry's promotional activities. The mountainous, landlocked, developing
country of Nepal, which has a population of about 23 million, has an annual per
capita income, in terms of purchasing power parity, of about US$2,000 in urban
areas and US$1,000 in rural areas. In Nepal, Western allopathic medicine
coexists with traditional medical practices like Ayurveda, Tibetan medicine, and
faith healing. Many rural areas lack access to modern health care, but Kathmandu
and other cities are becoming booming markets for pharmaceuticals.
Pharmaceutical Promotion and Its Impact in Nepal
The promotional activities of medical representatives (MRs, also known as drug
company representatives), and other promotional activities by pharmaceutical
companies, have a major influence on prescribing and on drug use by the general
public all over the world [1]. The World Health Organisation's Department of
Essential Drugs and Medicines Policy maintains a database of such promotional
activities at http://www.drugpromo.info. In Nepal, common prescribing problems
are polypharmacy, and overprescription of antibiotics and injections [2]. We are
studying prescribing patterns in our hospital and have observed excessive use of
expensive antibiotics, vitamins, and digestive and enzyme preparations. The
preparations prescribed are those that are actively promoted by MRs. I (PRS)
have sometimes found consultants recommending to the hospital Drug and
Therapeutics Committee that drugs of doubtful efficacy be included in the
hospital pharmacy, following visits by MRs.
Most hospitals in Nepal allow free access of MRs to doctors, and academic
detailing is absent. MRs bring with them many creative ideas for drug promotion.
I (BRG) observed this for the first time when I visited one of my professors. A
signboard next to the door read “Doctor is IN-DIGENE” (Digene is a brand of
antacid). After going inside, I noticed that there was at least one big poster
promoting a pharmaceutical company on every wall. On the table was a beautifully
handcrafted nameboard with the professor's name in golden letters. The side
facing the professor had the brand name of a drug in equally stylish lettering.
Medical conferences in Nepal are strongly dominated by the pharmaceutical
industry. Often, companies organize parties for doctors in which a continuing
medical education topic is followed by a lavish cocktail dinner—but often the
educational part is absent. One such party was recently organized by a
manufacturer of suture material and was attended by almost all the consultants
and medical officers of our hospital.
After doctors accept personal benefits from the industry, they might arguably
feel an obligation to prescribe the promoted drug. There is certainly good
evidence in the literature that such gifts from the industry are associated with
changes in prescribing behavior (the evidence is collected at
http://nofreelunch.org/requiredinfluence.htm). Pharmaceutical companies also
sponsor the activities of medical students (such sponsoring can take the form of
sports matches, publications, and parties). The industry expects a substantial
return for every rupee spent on doctors and medical students.
Often, though, the cost of promotion is directly recovered from the patient. A
lady I (BRG) knew once said to me, “I am taking only half the medicine. If it
works well then I will get more. It is too expensive.” The tendency to buy a
lesser amount of the drug or no drug at all is a common phenomenon in Nepal and
leads to therapeutic failure.
An Educational Initiative on Promotion
As a student at Manipal college of Medical Sciences (Figure 1), I (BRG) have had
the opportunity to experience an educational initiative on drug companies'
promotional activities. This initiative involves small groups of students in
interactive learning sessions. I have learned about common methods of drug
promotion; unethical promotion practices; ways in which promotional materials
give false impressions of the absolute and relative risks and the risk-benefit
ratio; and the interpretation of graphs used in advertisements and optimizing
time spent with MRs.
Class activities include critical analysis of promotional material and drug
advertisements against the World Health Organization's Ethical Criteria for
Medicinal Drug Promotion
(http://www.who.int/medicines/librar...ethicalen.shtml).
These criteria, prepared by an international group of experts, “constitute a
frame of reference for judging proper behavior in drug promotion, whether
involving the contents of advertisements and package inserts or the sponsorship
of scientific symposia, and the use of representatives.” The criteria “give
manufacturers, distributors, the promotion industry, prescribers and consumer
groups a framework to ensure that promotional practices are in keeping with
acceptable ethical standards.” Recently, role-play has been introduced into the
class activities to present the interaction between a MR and a doctor. The
interactions are critically analyzed by the groups. Students are assessed in
critical analysis of promotional material during the pharmacology practical
examinations.
Prescribers often do not realize the influence of promotional materials and
activities [3]. In our hospital, through the Drug Information Center, drug
bulletin, and other measures, we are sensitizing prescribers to critically
evaluate industry sources of drug information. Recognizing that it is easier to
inculcate good prescribing habits in future doctors, teaching and learning about
rational use of medicines and medicinal drug promotion are emphasized in the
medical students' pharmacology course.
Impact of the Initiative
There has been a noticeable impact on the attitudes of medical students towards
drug promotion. I (BRG) and my fellow students have been sensitized to the
negative effects of aggressive promotion. In our hospital, aggressive promotion
is evident but criticism is often difficult to make. When I discussed this essay
with an intern, he responded, “No MR will approach you. You will need them from
your internship onwards.”
I (PRS) am analyzing feedback obtained from a questionnaire about the
educational initiatives. Preliminary assessment showed that students were
favorably disposed toward and enjoyed the sessions. We are investing in the
future, and believe that around 10%–15% of our students have been convinced to
take a hard, critical look at drug promotion. “Enlightened” students will be an
important asset to their communities and countries. Long-term studies of the
impact will be carried out in the future.
Conclusion
The initiatives have helped me (BRG) critically analyze sources of information
from the pharmaceutical industry. In the future, I am confident that I will be
prepared for the sales pitches and gimmicks of the industry.
When prescribers are made aware of the methods used by drug promoters, it is
more difficult for unhealthy practices to take root; the ultimate beneficiaries
are the patient and the community. We (PRS and colleagues) plan to bring in
actual MRs to demonstrate the promotional techniques and to show videotaped
encounters between doctors and MRs. We plan to strengthen the role-plays in the
future. We are trying to enlist the support of the hospital's Drug and
Therapeutics Committee to conduct sessions on drug promotion for the interns and
medical officers.
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References
1. Laing RO, Hogerzeil HV, Ross-Degnan D (2001) Ten recommendations to
improve use of medicines in developing countries. Health Policy Plan 16: 13–20.
Find this article online
2. International Network for Rational Use of Drugs (2003) Training manual of
the 16th national training course on rational use of drugs, 13–18 October 2003.
Kathmandu (Nepal): International Network for Rational Use of Drugs. 66 p.
3. Holloway K, Green T (2004) Drug and therapeutic committees—A practical
guide. Available:
http://www.who.int/medicines/librar...DM_PAR_2004_1_D
rugs_and_therapeutics_committees.pdf. Accessed 28 June 2005.
http://medicine.plosjournals.org/pe...oi=10.1371/jour
nal.pmed.0020256
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