Postcard from Mumbai: The Same, only Worse

Thanks to the Indian Journal of Medical Ethics, we now have a peek at drug promotional practices in Mumbai, a qualitative study based on interviews with drug company executives, pharmacists (chemists), physicians, and drug reps. The findings largely reinforce the findings of the Consumers International report on drug promotion in the developing world (http://brodyhooked.blogspot.com/2007/11/consumers-international-report-must.html). Some highlights:

• Indian drug reps apparently make considerable use of flip charts to do their pitches--one rep said that Glaxo introduced these in 1972 and immediately doubled its sales, so now all follow suit. The docs never get to keep any information on the flip charts, and every few months the current charts are recalled by the companies and destroyed. There are commonly inconsistencies between what's on the flip charts and what's in the published literature.
• Docs are as readily brainwashed in India as here. All denied ever being influenced by "gifts" from the companies, though they all know of colleagues who had been.
• The "gifts" are of two levels. Docs receive the usual "reminder" items plastered with the company logo and drug brand name. But high prescribers also get more substantial "gifts" which today are usually blatant bribes, as the ever-more competitive drug marketplace demand that reps not give out big ticket items without proven performance. Some slum-neighborhood doctors were offered a cell phone handset for prescribing 1000 tablets of one drug, an air cooler for 5000, and a motorcycle for 10,000.
• The complexity of medical practice and the lack of legal oversight allow practices in India that would not occur in the U.S., such as chemists selling drugs without prescriptions, and traditional Indian (ayurvedic) physicians prescribing Western medicines despite being officially prohibited from doing so. Accordingly both sets of practitioners receive due attention from the reps.
• High tech seems not yet to have come to India--reps cannot get a computer download of their local physicians' prescribing patterns as they routinely can in the U.S. They have to go to the local chemist and pay for a prescription audit.
• Marketing extends sometimes to frankly defamatory campaigns waged against competitor drugs, often stressing side effects.

The investigators concluded, "A wide range of questionable, or unethical, or frankly illegal trade practices were described." They report with regret that few organizations representing any public interests currently seem to be taking a stand against these practices in India.

Roy N, Madhiwalla N, Pai SA. Drug promotional practices in Mumbai: a qualitative study. Ind J Med Ethics 4:57-61, 2007.