a Third World Perspective on the Ethical Dilemma of Drug Company Gifts
Who doesn’t love presents? Santa Clause, your mom, your boy/girlfriend – doesn’t matter who it’s coming from, as along as the tag has your name on it (and you don’t have to pay). Can you imagine if you could get presents, not only from people who care about you, but from people you associate with in the professional sphere?
What, presents from work colleagues? Not quite. Gifts and privileges from medical representatives trying to push their products. What’s the harm, you might ask. I’ll take their stuff, but my prescriptions don’t have to change. Besides, so what if I prescribe Brand X instead of Brand Y. The patient still gets the same drug.
But there’s plenty of harm.
Multi-million dollar pharmaceutical companies, affectionately called Big Pharma, spend tidy sums of money each year keeping physicians loyal to their brands. This comes across as fancy dinners, paid vacations, or even just catered meetings. The medical representative proffers the olive branch of food (usually) in return for the chance to remind physicians why we need to prescribe their pills.
This, of course, can have disastrous repercussions for patient care, particularly when the ethical practices of physicians are called into question. For this reason the relationship between doctors and drug companies is heavily regulated in the United States and other countries. But in Jamaica physicians are left up to their own devices when handling drug company influences.
For the most part the attitude of Jamaican doctors appears to be politely non-partisan. We’re appreciative of the benefits meted out by medical representatives, but brand loyalty isn’t a widely supported concept*.
In medical school our lecturers went to great lengths to teach generic names instead of brands for common drugs. It’s a habit that sticks until you start working with doctors who almost exclusively use trade/brand names and then all our lecturers’ hard work is undone. And strictly prescribing generics becomes impractical when you start to consider affordability, brand vs. generic efficacy (and there is a difference) and of course patient preference. Most of our choices as doctors will be based on one or more of these factors, not just which company gave us better stuff.
Another aspect of third world presents that differs from our first world counterparts is the quality and scale of the benefits. I hear stories (from the U.S.) of travel expenses being covered and expensive electronics being gifted to conference attendees. Big Pharma has even literally paid doctors cash to recommend their products.
Now I am a still a small fry in this medical business, but I just don’t see Lil Pharma here in the Caribbean shelling out that kind of money. We get catered lunch meetings and one or two free conferences for medical education purposes, but the average ‘kickback‘ here is most often a pen or some hand sanitizer. Really, it’s like they’re not even trying (by comparison).
But this doesn’t necessarily mean we aren’t being swayed. Especially when you add in other local factors like how Jamaica is so small that chances are you’re actually friends with one or two medical representatives (and so feel compelled to prescribe their drugs). Or how Jamaica has so much corruption that even if physicians practiced unethical brand loyalty people would probably still turn a blind eye. On the other hand, Jamaica is so poor that most patients aren’t able to afford fancy brands anyway so it’s not much use pushing those medications on our market.
This is where public and private practice diverge widely. Patients in the public system are treated based on availability of medication because for the most part they cannot afford to pay full price for their medications. Pharmaceutical companies sometimes bid for spots on the National Health Fund subsidy so that their drug can reach a wider base. Yay, right? Not necessarily. These are the cheaper drugs, often generic formulations and usually older than what the rest of the world is using. Standard of care takes a back seat to any kind of care we can manage at this point.
By contrast in private practice, patients are generally seen as wealthier and more actively involved in their health. These patients usually don’t mind paying more for a brand name medicine if they feel it works better than the generic, and this is where the industry can get a toe in the door. This is where the ethical dilemma of industry gifts begins to take root. And if we are going to start any kind of regulatory or even supervisory process this is where we must investigate first.
But for now people are comfortable. Patients get their medications, physicians get their food, and Big Pharma gets their profits. It’s a win-win-win, until someone (likely the patient) loses.
*Not statistical. Based on my own (limited) observations.