March 10, 2002

Direct-to-consumer advertising is likely to be a feature in most countries under the intense and sustained pressure of multinational firms that have a typical marketing wisdom which says that in order to sell the cure, they have to first sell the disease

THE doctor, once a godly figure in society, is on the brink of partly losing his traditional role of a healer. For some immodest reasons, he is being denied the undeniable status of having a ‘final say’ in matters of prescribing a medicine by the market forces. And for the medical elite in Pakistan and elsewhere who always prided themselves on their great skill of prescribing the right medicines, it may be like a bad dream coming true.

The global pharmaceutical industry has recently launched a major offensive to establish a direct relationship with the patient to sell its major prescription medicines under what is called DTCA — direct-to-consumer advertising. Under this legal framework, the industry is creating what it calls the “informed and empowered” patient by furnishing him with all the information he needs about certain diseases and certain medicines through advertising on TV and radio and in newspapers and also by mailing to him print literature.

The purpose is to enable him, as the industry claims, to discover his ‘hidden illnesses’ and also to decide about which medicines to use to treat his ‘known’ illnesses. After being influenced by the drug ads, the ‘expert’ patient will then influence his doctor to write prescription drugs of his choice. In case the doctor refuses to do so, the patient shall go to another doctor. The purpose of the whole exercise is that a patient should change the doctor, not the drug.

The DTCA has been a success in the United States. Europe is resisting it, but may give in soon. The Third World is hardly a problem because over-the-counter (OTC) sale of all kinds of medicines is already rampant there, and it will only be a matter of having a new law.

But the question arises: why DTCA? A short answer is that the pharmaceutical industry is in a crisis because of, what it says, low profits. The companies are no longer able to innovate enough to grow — a problem so far largely obscured by frequent mergers and acquisitions. So they can survive in their present shape only by expanding markets and selling ‘blockbuster’ drugs which, they think, is possible through “patient pull”. But more on this a little later, first on the DTCA.

Direct-to-consumer advertising is at present illegal everywhere except the United States and New Zealand. It became legal in the US in 1997, but has never been illegal in New Zealand. For the industry, the victory in the US wasn’t so easy. It lobbied very hard, very cleverly and for a long time. When it came, the healthcare professionals strongly objected to it and the Food and Drug Administration (FDA) hardly welcomed it. But in a country where even pornography gets by under the First Amendment, there was no way of stopping the DTCA, especially when the TV and print media were also to gain the most.

Within a few months of its becoming legal, the amount spent on direct appeals to the public had exceeded what the industry spent on advertising in medical journals. Last year, a survey revealed that patients’ requests to doctors for drugs of their choice have gone up by 59 per cent. Prescription drug manufacturers spent 1.9 billion dollars on DTCA in 1999, an increase of 150 per cent since 1997. Competition through DTCA is likely to become more intense in the future. The DTCA spending by companies jumped by 58 per cent between 1999 and 2000.

The February 2002 issue of the New England Journal of Medicine says that TV advertising of prescription drugs in the US tripled between 1996 and 2000. The industry spent nearly 2.5 billion dollars on direct appeals. The most heavily advertised products were arthritis drugs Vioxx and Celebrex, the ulcer drug Perilosec, Viagra for impotence, and the allergy drugs Claritin, Allegra and Zyrtec. Sixty per cent of the print and broadcast ads were for just 25 medications.

However, the money spent on wooing doctors still remained the largest chunk — the industry gave samples to physicians worth eight billion dollars and spent 4.8 billion dollars in sales visits to hospitals and clinics.

Although there are no two opinions about the development that more people are now taking more medicines, disagreement remains whether it is a positive trend. What has happened over the years is that the flood of ads has persuaded Americans to take pills they don’t need. The DTCA has played a significant role in promoting SSRI anti-depressants in general, and Prozac in particular.

Last year, Eli Lilly spent 41 million dollars on DTCA, which was twice of what it had spent the year before. In Britain, the industry sponsored the Defeat Depression Campaign run by the Royal College of Psychiatrists. This led to promote the idea that depression was widespread and vastly undertreated, but well conquered by drug companies and that it was safe.

For how long Europe can resist the industry’s offensive is not difficult to perceive. Last July, the European Commission released a proposal that would allow pharmaceutical companies to promote prescription medicines for three types of illnesses — AIDS, diabetes and asthma — directly to consumers for a period of five years on a trial basis. Currently, the DTCA is banned within EU member states. This proposal, critics say, is the first step towards Europe’s ultimate surrender to the drug industry and that the DTCA will become a reality within five to ten years.

The proposed measure, the EU says, is part of a “disease awareness-raising” campaign so as to alert the consumers to the conditions they might not have realized were treatable or to provide more background about the chronic diseases. This is being done, in fact, to put pressure for the desired change. And it is in keeping with the typical marketing wisdom: in order to sell the cure, you have to first sell the disease.

Such campaigns have recently been carried out in the United Kingdom, Spain, The Netherlands and other European countries. The consumers’ need to have more information about prescription drugs is not a problem. What is, in fact, the problem and where industry comes into clash with the doctor is the nature of the information. The doctor wants it to be unbiased, industry wants it to be (drug) promotional because its objective is profit.

The drug firms, it goes without saying, advertise their newest products to gain market share. Whether or not they are safer or more effective is a separate matter. But they are definitely costlier. In a few words, the main goal of advertising is to increase product sales. It does not necessarily enable the consumers make informed health choices. Then the prescription drugs are not like other consumer goods. They can also cause serious harmful effects if consumed without proper medical advice. The World Health Organization (WHO) says that advertising should not be treated as an educational activity.

As far as the subcontinent is concerned, conditions are totally different. Direct appeals to the consumers by the multinationals, despite a law banning it, are not uncommon. In 1996, Eli Lilly gave the general practitioners in Pakistan an information brochure on Prozac for placing it in their waiting rooms. The brochure contained a questionnaire, to help patients diagnose themselves if they suffered from depression, and a statement encouraging the patients having depression to take “one capsule of Prozac every day”, thus, implying that self-medication is appropriate. The episode drew protests from local health NGOs.

A recent study of retail pharmacy sales in India shows a growing increase in direct-to-consumers sales of prescription medicines, although it is illegal there. In 1994, about 50 per cent of medicines were sold without a doctor’s prescription, up from 38 per cent in 1986. Most of these drugs were officially classified as prescription-only and about one-fifth were antibiotics.

Regarding how the DTCA phenomenon took shape, the industry’s apologists trace the problem to the fact that major companies depend for their future well-being on pharmaceutical innovation and that new drugs are not coming through at the desired rate. Hence, the industry is now more and more depending on blockbuster drugs (drugs with sales of $500 million a year or more). But to have such drugs huge investments alone are not enough; in most cases fewer than four per cent of all new chemical entities achieve ‘blockbuster’ status.

In order to sustain average growth, the industry says, a company must introduce every year one new product. And a company of the size of GlaxoWellcome/SmithKlineBeecham needs three to seven products each year in order to keep good health. Pfizer was able to bring two drugs to the market a year which, its R&D chief John Niblack says, is not enough “at this stage of market consolidation”.

This also explains the continuing urge to merge. The drug giants need more and more capital to continue research and launch new products and twice as much to promote them. Mergers are a short-term remedy and aggravate the situation in the longer term. This is one reason why the British drug industry is gradually moving towards the United States.

But this is not the whole story. According to a November 2001 survey conducted by Kaiser Family Foundation, a well-known non-profit health campaign organization, the pharmaceutical sector continues to earn the highest profit rate in the industry as a whole. And a similar study done last July by Ralph Nader’s The Public Citizen, a prestigious health research group, says that the drug industry actually spends about one-fifth of what it claims it spends on developing new drugs. Actually, it spends two or three times more on sales promotion. For instance, GlaxoSmithKline spent 37 per cent of its revenues on marketing in 2000, and only 14 per cent on R&D, and made an overall 28 per cent profit.

The hard fact is that the pharmaceutical sector has become a profit-addict industry and it feels uncomfortable with low profits. It knows it can make higher profits simply by raising prices and applying good marketing techniques because, it also knows, the patients are usually willing (or feel compelled) to buy the products regardless of the price tag. And no government is inclined to confront the pharmaceutical firms, and, instead, prefers to ignore their shenanigans.

There are all the indications that most of the countries will ultimately allow the DTCA. In the emerging free market, which we cannot wish away, the doctor may have little option but to ‘cooperate’ with the industry and prescribe what the ‘expert’ patient asks for, even if the requested medicine happens to be inappropriate.

In theory, the DTCA can be kept at a distance by the medical profession and the patients organizations by offering stiff resistance. In practice, the vested interests are too strong with covert influence sloshing around to be resisted successfully.

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