The pharmaceutical drive to drug. (Technology & Society).

In a manner of speaking, the twenty-first century equivalent to the traveling huckster who preyed on ignorance and insecurity to sell patent medicines and other concoctions of dubious efficacy may be the multinational pharmaceutical industry. There is Viagra for women, drugs for the concocted "illness" of decreasing bone density of aging women, cure for hyperactivity disorder in adults, sixty new obesity pills, Prozac for seven year olds, and a pill to curb the urge to shop.

Like all business enterprises, the pharmaceutical industry must constantly expand. It does this through innovation in product and marketing. The latter is seen as more cost effective and much less prone to regulatory interference. The money spent on drug advertising is truly astounding--estimates are no longer in the billions but in the tens of billions, and increasing rapidly. According to a December 12, 2002, New York Times article, "Promotional spending in the United States by the 14 largest [pharmaceutical] companies increased at an average annual rate of 32.4 percent from 1998 to 2001." In 2000 Merck spent $161 million on advertising for one drug, Vioxx, which is more than was spent in advertising for Pepsi ($125 million) or Budweiser ($146 million). The most important, though rarely analyzed, way in which drug firms advertise is in one-on-one conversations with doctors, which increases the budget. According to a June 24, 2002, Wall Street Journal article, "There is little dispute that drug makers spend big money--more than $16 billion in 2001, according to one estimate--cultivating physicians and medical students."

Advertising to doctors takes many forms. Traditionally, company representatives (who are often attractive women) meet with doctors to discuss the drug, provide information, and frequently give free samples. There has been a proliferation of these representatives in recent years. According to a February 15, 2003, article in the Economist, "The number of drug reps in America alone has almost tripled since 1995, to some 90,000 last year, even though the number of doctors has barely budged." Likewise, the amount and types of gifts physicians receive is increasing. Sometimes company representatives wine and dine them or take them golfing. Trips to the spa and ski holidays have also been made available. As the Economist article reports, "Police in Verona, [Italy,] raided the offices of GlaxoSmithKline; now 40 staff and 30 doctors are under investigation for comparaggio--prescribing drugs in exchange for gifts, such as computers and lavish trips."

According to a December 18, 2002, Wall Street Journal article, in addition to wooing doctors individually, the drug industry

   hires as consultants leading doctors as
   "thought leaders" who talk up the pills or
   the science behind the pills at medical
   meetings.... The big drug makers provide
   60% of the financial support for continuing
   medical education classes, often using the
   sessions to promote medicines as doctors
   keep their credentials up to date. They provide
   funding for patient-advocacy groups
   that in turn help to promote newer, more-expensive
   medicines. And they use sophisticated
   marketing campaigns to persuade
   doctors and patients to switch to new, but
   similarly effective compounds when patents
   on big-selling drugs are about to expire.

There is no legitimate reason for companies to give physicians gifts. U.S. government regulators are currently working on a voluntary guidance proposal for interactions between drug firms and doctors, but such regulation makes little sense--gifts from drug companies should be illegal. On the other hand, some well-regulated drug advertising might be a way to keep physicians educated. One would hope that physicians--people who help us make life and death decisions--prescribe drugs based upon science, not manipulation. Unfortunately, this is not always the case. The December 12, 2002, Wall Street Journal article quotes a 1982 study conducted by Jerry Avorn and colleagues at the Harvard Medical School in Boston, Massachusetts:

   Although the vast majority of practitioners
   perceived themselves as paying little attention
   to drug advertisements and [salespeople], as
   compared with papers in the scientific literature,
   their belief about the drugs revealed
   quite the opposite pattern of influence.

The article explains the importance of this study today: "Not much has changed since then except the drug industry's spending on promotion" has increased.

Beyond courting medical professionals, drug companies in the United States can engage in direct-to-consumer (DTC) advertising. Changes to Food and Drug Administration (FDA) regulations in 1997 sparked a flood of DTC advertising of prescription drugs on televi1sion and radio. Now American viewers and listeners are bombarded with the wonders of a multitude of new nostrums. The European Union is currently debating the issue, and Israel Asper--Canada's leading media mogul--recently denounced government regulation on DTCs. While DTC advertising seems to have improved the health of drug companies, has it done the same for the health of the general population?

Treatments for hyperactivity disorder is a good example of the dangers of drug company advertising aimed at consumers. According to a January 5, 2003, Montreal Gazette article, "The market for hyperactivity treatments grew to $1.1 billion in 2001 from $400 million in 1995 as Shire and others started to advertise and promote their treatments more widely. Companies put ads in such magazines as People just before the start of the school year, for instance, urging parents to see their physicians about concerns over their child's behavior." In effect, drug companies decided they could make money by exploiting parental insecurities, causing parents to medicate their children.

Pharmaceutical companies are now eyeing the adult hyperactivity market. The FDA recently approved a couple of hyperactivity drugs for adults despite the scientific debate about whether this is even a valid medical condition, and drug companies are pushing adult and child hyperactivity "disorder." The issue of hyperactivity drug abuse was well summarized by Lawrence Diller, a physician quoted in the January 5, 2003, Montreal Gazette article. He says, "We're looking at a major stimulant-abuse problem in the next five or 10 years."

The pharmaceutical industry often benefits from the branding of new illnesses. For example, twenty-five years ago depression was a problem seldom considered in the medical world. Today, however, it is generally accepted as a serious illness--a positive development for sufferers and a huge help to the bottomline of the drug industry. Pharmaceutical companies can claim to be progressive when promoting drugs for new illnesses, but it is sometimes difficult to differentiate between genuine medical advancement and vested interests pushing their products.

Drug companies claim that hyperactivity drugs help children learn, which may be true. It is certainly true that it is in the drug industry's interest to simplify a complex issue. Some childhood hyperactivity has been linked to problems with the education system--energetic children forced to sit and concentrate for long stretches when they should be given more freedom--but complexity is overlooked for a short-term fix, since this is more profitable to the pharmaceutical industry.

The drive to drug is part of a deeper problem with the pharmaceutical industry, especially in the United States. Ever-expanding pharmaceutical advertising, which is mainly due to DTC advertising, is only profitable within a liberalized price structure. In the United States there is little in terms of price controls on pharmaceuticals. Companies free to charge high prices can spend huge sums on advertising and still maintain large profits. Aside from directly regulating advertising, price controls are a way to reduce it. According to the December 12, 2002, New York Times article, drug companies "spend 12 times as much to promote their prescription products in the United States than in Europe's largest medicine market, Germany." This is a significantly larger sum since the United States is little more than three times the size of Germany. Increased German restrictions on drug advertising as well as price controls are important factors. In fact, while drug advertising has been skyrocketing in the United States, the Times reports "in France and Britain, marketing spending fell at an annual rate of around four percent from 1998 to 2001. Both countries have laws that limit drug marketing and prices."

Still many will argue that some good comes out of all this pharmaceutical industry spending. High profits could mean more research, but to whose benefit? Drug companies are complicit in a serious imbalance in world health resources. Medical health officials call it "the 10/90 gap." This describes the current state of affairs in which less than 10 percent of the investment in worldwide health research is spent to study 90 percent of the world's health problems. This misallocation of funds manifests itself in many ways. According to Medecins Sans Frontieres' writing in the May 13, 2002, Scientist,

   Of 137 drugs in the pipeline to treat infectious or parasitic
   disease, one targeted sleeping sickness and one, malaria.
   Yet eight drugs are in clinical trials for erectile dysfunction,
   seven for obesity, and four for sleep disorders. The
   most neglected diseases affect predominantly people in
   the Southern Hemisphere who do not contribute to the
   pharmaceutical market.

If well regulated both in terms of advertising and costs, drugs can positively affect people's lives. Better drugs to prevent or cure malaria and sleeping sickness could save millions. Most likely, however, these won't be discovered anytime soon because it isn't profitable enough to do so. According to a May 30, 2002, New York Times article, business investment flows where profits are greatest; "highly innovative new medicines--those with new chemical ingredients that offer significant improvements over existing drugs--made up only 15 percent of those approved" between 1989 to 2000. Nancy Chockley, president of the National Institute for Health Care Management, said, "This is more evidence that the pharmaceutical companies are turning into marketing companies."

Yves Engler is a freelance writer based in Montreal, Quebec, Canada, and the vice-president of communications for the Concordia Student Union at Montreal.