Pharmaceutical Industry: Good or Evil?

Bringing attention to certain medications that everyone should ideally have access to by highlighting them as the “essential medications” seems like a good idea. But who gets to decide what medications are essential or non-essential; where do we draw the line? The criteria for the first list of essential medications in 1977 were based on clinical trials of safety and efficacy conducted in the global North (mainly developed countries) and cost-effective analyses in a developed nation’s economy (Greene, p. 19). Does this make sense, considering health outcomes and access to health care are vastly different between developed and developing nations as well as within each category?

As Jeremy Greene explores the (surprisingly) recent history of pharmaceuticals in global health in his article, many questions regarding “essential medications” come to mind. Something that worried me about defining essential medications in the form of a list was that such a list would affect how insurance companies consider coverage for certain medications over others. A focus on medications used to treat common diseases (Greene, p. 18), may pull attention away from essential medications for rare diseases. This could be connected to multiple harmful effects: pharmaceutical companies may not have much incentive to invest in research and development of new medications to treat those rare diseases because such products would only yield small profits from a small market, and health insurance companies may not be inclined to cover treatment involving medications that are not listed as being essential.

Greene mentions the “drug-dumping” of multinational pharmaceutical firms as they purposefully sold their products, some of which had not completed clinical trials and had questionable safety and efficacy reports, in countries with less regulations on the quality of drugs in the 1970s (Greene, p. 16). To me, this situation mirrors that of the tobacco industry, in which major tobacco companies started looking for foreign markets outside of the United States with the rise of foreign demand in the 1960s. Taking advantage of the weaker restrictions on trade and health regulations in developing nations, tobacco companies targeted women and children in Africa and China, for example, to expand their market and increase profits (Brandt, p. 454, 487). In some ways, pharmaceutical companies are just as manipulative and selfish. In response to the South Africa’s Medicines Act of 1997 that allowed for the production of generic versions of patented HIV drugs to make them more affordable to a greater population, thirty-nine pharmaceutical companies filed suit in South African courts just a year later. Furthemore, the U.S. government also expressed its disapproval, even though it later changed its mind in support of the Medicines Act in 1999 following uproar from political activists (Farmer, p. 122, 123)

Nowadays, the “cozy” relationship between doctors and pharmaceutical companies has become controversial. It is no secret that major pharmaceutical companies and doctors often work closely together – drug companies send sales representatives to speak to doctors about new medications and sponsor medical education and research. This has raised questions of conflict of interest – doctors can monetarily benefit from prescribing certain medications, biasing them towards providing certain treatments over others that could be just as effective or more effective (Glover). However, others including cardiologist Dr. Lisa Rosenbaum argue against the stigma surrounding doctor-industry collaborations. In her opinion, such a collaboration could lead to “life-saving therapies whose development requires the combined talents of clinicians and industry” (Rosenbaum). Dr. Rosenbaum contends that the conflicts of interest argument could lead to important viewpoints being discredited or ignored, simply because a doctor happens to work with drug companies

As part of the Affordable Care Act of 2009, the Sunshine Act mandates that all payments over $10 from pharmaceuticals to doctors or hospitals be made public to increase transparency and disclosure (Glover). Even so, there is always the risk of a doctor building close ties with one specific company and endorsing their products at every opportunity, blinding himself to potentially better options available for patients. The Access to Medicine Index (ATMI), implemented in 2008, is another way to keep pharmaceuticals accountable. The ATMI publicly recognizes companies for their efforts to improve access to drugs in developing nations. By ranking countries in order by their commitment to the transnational goal distributing drugs globally at reasonable prices, the ATMI encourages companies to keep up their efforts. Another way of looking at the list and rankings is that the ATMI puts pressure on the companies that ranked low on the list or did not make the list to work towards equal distribution of medications (Greene, p. 27).

Discussion Questions:

  • The Second Model List of Essential Drugs clarified that drugs not listed were not necessarily “inessential” and that the list was mainly meant to be used in the context of developing nations with the goal of making medications more affordable and accessible. Do you feel that the Second Model List of Essential Drugs adequately addressed problems of the first list?
  • While some argue that doctors working with pharmaceutical companies and being financially compensated for prescribing certain drugs will lead to biases that could potentially be harmful to the patient, others firmly believe that we could be losing out on life-saving advancements that may result from such collaborations. What do you think about doctor-industry collaborations? Is there a “happy medium” in this situation?

Course Readings:

  • Brandt, Allen. (2007). The Cigarette Century. New York: Basic Books (p. 448-492)
  • Farmer, A. Kleinman, J. Kim and M. Basilico. (2013). Reimagining Global Health: An Introduction. Berkeley: University of California Press (p. 122-123)
  • Greene, J. A. (2011). Making medicines essential: The emergent centrality of pharmaceuticals in global health. BioSocieties, 6(1), 10–33. http://doi.org/10.1057/biosoc.2010.39

Outside Readings:


UPDATE (on Nov. 25, 2015 at 10:30pm): 

At the end of September, Turing Pharmaceuticals announced a 5000% price hike of their drug, Daraprim (used to treat toxoplasmosis, especially in immunocompromised HIV/AIDS patients), from $13.50 to $750 per tablet, which (unsurprisingly) resulted in a public uproar. As I was following this story, it at first seemed that Chief Executive Martin Shkreli saw nothing wrong with this overnight price increase, reasoning that pharmaceuticals need to make money for drug research and development. (He is quoted as stating, “It is us trying to stay in business” in the New York Times.) Since then, he seems to have finally come to his senses and has announced that the price of the drug will be cut by up to 50% for hospitals only.

However, this shows just how much “power” pharmaceuticals can have over prices of their products and how they can wield this control in a way that affects the public as a whole. This is not an isolated incident in recent news. A similar price increase was applied to cycloserine, a drug used to treat tuberculosis, although this price increase was rescinded soon after. What loopholes in policies regulating pharmaceuticals allowed these significant price increases for important drugs to occur, and how can the government make sure nothing like this happens again?

Dec. 8th, 2015 at 9:50am: Sarah and I have been discussing (in the comments below) about possibly having more interaction between the government (the U.S. government in particular, since several of the major pharmaceutical companies are based here) and an established and reputable international organization such as the WHO. The purpose of this collaboration  would be to ensure that drug companies do not raise prices of their products just to make more profits. Although the WHO, a branch of the UN, does not have any teeth and does not hold direct power over national governments (as we discussed in class), I believe it would be more efficient to utilize an already established organization rather than creating an NGO from scratch, as an NGO would not hold any power over a state’s government and pharmaceutical corporations, either. The WHO would be able to monitor which organizations are engaging in philanthropy by donating important medications that would otherwise be prohibitively expensive to populations in low- and middle-income countries that need the medications, thereby encouraging other pharmaceuticals to follow suit. Because the WHO does have sway over international publicity, the organization could also publish data on what pharmaceuticals have dramatically raised prices on their products, adding to the pressure on these pharmaceuticals to reduce their prices to make their drugs more affordable.

FURTHER UPDATE (on Dec. 7, 2015 at 11:09pm):

I realize I was not very clear about how such pharmaceuticals were “allowed” to raise the prices of their drugs so drastically. Pharmaceuticals like Turing have found a loophole whereby they purchase all rights to the drug and then raise its price. This is perfectly legal, but legality does not always equate to morality, as we discussed in class in the context of corporate responsibility (e.g., Shell’s environmental pollution in the shantytown of Flammable, Argentina). While the connection between the social suffering and corporate responsibility is not as clear-cut in the case of these pharmaceuticals’ price hikes, I believe there needs to be more regulation on drug prices.

According to a Wall Street Journal article from December 5th, 2015,    there will be a congressional hearing on December 9th between the Senate Special Committee on Aging and pharmaceuticals with price jumps, including Turing Pharmaceuticals, to investigate the problem. Hopefully, this will further emphasize the message that we civilians (and most politicians) will not tolerate drastic price surges of important drugs and push forward policies to prevent another occurrence.

Dec. 9th, 2015 at 7:41 pm: Read more on the congressional hearing held this afternoon in Washington, D.C., where Senators Susan Collins and Claire McCaskill, along with specialists in the U.S. health care system such as Drs. Erin Fox and David Kimberlin, criticize four pharmaceuticals that have sharply increased the prices of their drugs out of greed for profits: http://www.theguardian.com/us-news/2015/dec/09/drug-companies-turing-valeant-martin-shkreli-daraprim

Sources:

 

33 thoughts on “Pharmaceutical Industry: Good or Evil?”

  1. Yuki, thank you for your insightful comments on the role of pharmaceutical companies in global health. While I certainly agree that in some situations, pharmaceutical companies have acted in their own best interest, and at time mirrored the tobacco companies, I do not think that these companies are all bad. Many pharma corporations include corporate social responsibility into their business model and today, pharma companies have contributed a significant amount of money to global health and NGO’s. I found the point you raised about the essential medicine list being an obstacle to research particularly interesting. I definitely agree, that creating such a list could harm medical research because it would not be as profitable. Additionally, these drugs still in development could be medications to treat diseases such as HIV/AIDS or malaria. By disincentivizing the creation of new drugs, it could stop NGO’s from providing truly important medications to people who desperately need the medications. This is one reason I feel that the Second Model List of Essential Drugs did not adequately address the problems from the first list. Furthermore, I find wrong to consider a list of medications that would be essential in a developed nation could not also apply to what is essential in a developing nation. This idea comes back to Farmer’s argument that money should not be an obstacle, and everyone should have access to the same level of care and medication. While this may be true, how do we achieve this? How do we get pharmaceutical companies to put aside profit making ventures and make certain medications more affordable to everyone around the world?

    1. Hey Sarah,
      Yes, for sure, many companies have incorporated social responsibilities as part of their mission. Merck and Pfizer are leading examples. These companies in particular have programs to donate medication to developing countries to treat river blindness disease with the overall goal of eradicating this infectious disease. But I think in today’s world, there is more scrutiny on companies that are focused solely on profit. Recently, Turing Pharmaceuticals and Rodelis Therapeutics have received many criticisms and negative publicity for their sudden price increases on their drugs, leading them to promise to reduce prices to affordable costs. I think using ATMI to pressure companies to work towards global distribution of medications is a good place to start. Like you mentioned, I think most companies nowadays re-evaluate the balance between serving people and making a profit, especially since the risk of bad publicity and reputation damage is so great.

      1. Hi Yuki,

        I definitely agree that using ATMI to pressure companies into lower drugs prices and distributing medicines worldwide is key. After reflecting on this course, it it very upsetting to realize how many people don’t have access to drugs they desperately need just because drug companies want to make a profit. If anything constructive is to be done to lower drug prices, I think an international regulator has to get involved and strongly influence drug companies to lower their costs. The WHO seems like the logical choice, but with all our discussion about how the organization has no teeth, I don’t see it as the best option. However, I don’t know who would be a better choice, since the US government has proved it supports the pharmaceutical companies and their pursuit of profit.

        1. Hey Sarah,

          As you discussed, it is a difficult situation with no easy answer. I’m not sure there is a “best option” with the infrastructure we have so far. But I do believe that working through the WHO to encourage pharmaceuticals to lower their drug costs or to engage in more philanthropical donation programs would be a good place to start. Perhaps the WHO could work more closely with the US government, since many major drug companies are based in the US.
          The link below offers more information about the pharmaceutical industry’s influence on the prices of drugs on the world market. It really is unfortunate that the WHO has basically no authoritative power on the regulation of drug prices, as this allows pharmaceutical companies to raise prices to increase profit.
          http://www.who.int/trade/glossary/story073/en/

          1. Hi Yuki,

            Thanks for the link, it was really informative! The numbers are staggering and a little demoralizing. I agree that since the WHO is already an established organization it would be simple if it could serve as some form of regulator. Do you think it is possible to give the WHO more power when it comes to matters of international health, such as lowering the costs of pharmaceuticals? Would it be effective to give the WHO more power, or would this lead to corruption? I have no idea what this would look like or how this would be achieved, but it I think it would be more straightforward than trying to establish a new regulatory entity.

          2. As an organization of the UN (with the exception of Security Council), the WHO can’t hold much power, and there really isn’t any way to give it sway over countries’ governments, as far as I know. I think the most it could do to influence drug prices would be to publicize which pharmaceutical companies are participating in philanthropy (i.e., donating medications to populations that need the medication, especially in LMIC) or are offering substantially reduced prices to make their drugs affordable. But yes, I agree that if there were a way to give the WHO or any other established, well-known, and respectable organization more power over this issue, it would be a step in the right direction.

  2. Hi Yuki,

    I really enjoyed you blog post on intentions of pharmaceutical industries and how it touches upon doctor-industry collaboration and the list of essential medicines. I agree with you in that having an essential list of medicines incentivizes pharmaceutical companies to focus their research on prevalent diseases that already have many drugs for them instead of researching cures for rare diseases that do not have any dugs developed yet.

    I think that although the 2nd list of essential medicines did resolve the issue of other medicines not being inessential if they were on the list, this resolved things only for the other pharmaceutical companies. The issue with the 1st and 2nd list of essential medicines ties back to the debate of whether developed countries should be the ones to decide what developing countries need without asking the community or government of these countries. Not only are we implementing an ideology of health and medicine for all to developing countries, but we, as a developed country, have not achieved this yet (as we saw in Samantha’s blog post). Does this therefore give us the right to go and tell people what they need to do?

    Concerning your second question, I think that the idea of doctor-industry collaborations is a very sensitive and controversial topic. On the one hand, this collaboration could lead to the misuse of certain drugs since the doctors will be more biased to use the drugs from their collaborators, even if they know another drug would work better. But on another hand, these collaborations, as you mentioned, can be a good way to advance in improving medications that are produced. Therefore, I think that this collaboration should take place but that there should be more regulations on the allowed amount of drugs from the collaborating company that are prescribed.

    1. Sorry, I meant “I think that although the 2nd list of essential medicines did resolve the issue of other medicines not being inessential if they were *not* on the list, this resolved things only for the other pharmaceutical companies. “

      1. Hey Claire,
        I really like the point you brought up about the morality of developed nations “imposing” their views on essential vs. inessential medicines on developing nations. This is definitely something to consider, since different societies may value “health” in different ways – while some may consider mental health to be of utmost importance, others may pay more attention to treating infectious diseases, for instance. And even within a specific type of disease (e.g., TB), there are varying degrees of values of health depending on culture. Some may focus on treating active cases of TB (e.g., symptoms of constant coughing), while others may be in favor of trying to completely eradicate the disease by finding latent cases of TB and treating these patients with chemoprophylaxis.
        How can we incorporate such considerations of differences among societies (not just developed vs. developing nations, but subgroups of populations within countries) when constructing a list of essential medications?

        1. Hi Yuki,

          Thank you for your insight on the degrees of values of health depending on culture through your TB example. Taking this into consideration, I think that the list of essential medicines is better the more specific it is to a population. Like we talked about in class and in your post, the problem with the current list is that it does not take into account the differences between developed and developing countries. However, even different developing countries have different cultures, religions and disease predominance, and I think that they should definitely be taken into account. I think that one way to tackle this problem would be for each community and their government to decide and draft their own list of essential medicines. This would allow each population to decide which diseases should be tackled as a priority on this list, based on how burdensome they are in their community.

          1. Hey Claire!

            I definitely agree that a community, in partnership with the local government, should delineate its own guidelines for essential medicines. If a volunteer organization from a developed nation (or an NGO) were to come into the situation to try to help make this list, then the organization should work with the community and its governing body to ensure that the list that they make is specifically tailored to the community’s needs and priorities.

  3. Hi Yuki,

    I found your blog post to be very informative, and it really highlights the incentives and the importance of pharma companies with their role in global health. I think you raise a very important point regarding the impact that the essential medicines list has had on pharma companies and doctors.

    The Second Model List of Essential Drugs, in my opinion, adequately addresses the many of the underlying problems that arose from the original list. With the first list of essential medicines, many concerns and criticisms arose because some believed that the drugs that were left off the list were considered “inessential” and therefore unworthy of the attention given to the ones listed. However, not all of the problems from the original list were addressed with this second list. On an ethical level, I do not think that those of developed nations should be able to decide what is “essential” for those of developing nations. While companies may have profited from this second list, the ones who are receiving the care did not profit. I believe that the creation of the second list was an incentive solely for the pharmaceutical companies, as opposed to the patients from the developing nations.

    In response to your second question, I believe that the doctor-industry collaboration can produce a “happy-medium.” Yes, this collaboration can lead to biased profit-based incentive, but it can also lead to the enhancement and better recognition of health initiatives that need to be taken, as well as the enhancement of certain medications.

    1. Hey Julianne,

      I agree with both you and Claire that developed nations should not be the ones to decide what medicines are “essential” for developing nations. It seems rather patronizing for developed nations to decide such things for developing nations. There are stark differences between the two categories, and even within each category, each society has its own nuances on how they view health.

      I also agree with you on the point that there can be a good balance in the doctor-industry collaboration debate. But what governing bodies or organizations can ensure that doctors aren’t biased too much by pharmaceutical companies? Of course, doctors (usually) have the patients’ best interests in mind, but what steps can be taken to ensure this collaboration doesn’t unintentionally harm patients in regards to what medications are prescribed by doctors?

      1. Hi Yuki,

        You raise a really good question here. In general, I feel that this potential for bias can be controlled through regulation by the government. The governments can regulate the profit-based incentives of the pharmaceutical companies with the actual care and prescription given to customers/patients. However, I am aware that this is a very difficult task to fulfill. Do you have any suggestions as to how this can be regulated through the government?

        1. Hey Julianne,

          I briefly mentioned this in my responses to Leah and Lindsay, but I feel that a system where doctors are held accountable for their decisions to prescribe one drug over another would be one way to address this issue. In the way I am envisioning such a system, physicians would have to state their reasoning for why they choose to prescribe one company’s drug over a similar drug produced by another company, especially if the physician has financial ties with one of the companies. You mentioned the role of government in regulating the potential for bias due to the financial incentives, but I am wondering what level of government should be responsible for this system. Would it be local/state governments, rather than national?

          1. Hi Yuki,

            Thank you for your response – I think you bring up a really interesting solution here. In response to your question, I think it would be more logical and effective for state and local governments to be responsible for regulating the potential bias. I think local and state governments could have a deeper focus on these biases, as opposed to the national government that has many pressing issues on their hands.

          2. Hey Julianne,

            I agree with you there in that local/state governments would be better able to handle the details of the monitoring system. That way, there’s less chance of some of these cases slipping through the cracks, and doctors can be held accountable for their decisions more easily.

  4. While I think the Second Model List of Essential Drugs made an important clarification about drugs absent from the list, I do not think it completely fixed the original list and the implications. It is still very black and white to have some drugs considered essential and others somewhat essential but less so. I think that instead of creating a concrete list, medicines should be ranked by priority. This should be different for different countries and communities, and helps address the problem of leaving out certain medicines that are not considered completely essential but still important.

    As for your second question, I think there can be a happy medium in doctor and pharmaceutical company collaborations, but it is a difficult balance to strike. There should be a system where doctors are accountable for their decisions, and should be able to prove prescription of one medication over another if there is suspicion of unwarranted collaboration.

    1. Hey Leah,

      I really like your idea of ranking medications by priority, but I’m very curious to know what factors you would consider when ranking them. Would you be taking into account what diseases/illnesses are most prevalent in each region, what health care resources and medications are available/lacking, what the community feels is the most burdensome disease, for instance? And who would be ranking these medications – would it be the WHO or a different organization? Would it be an organization with the help of community health workers, perhaps? (Sorry for posing all these questions to you; I’m just genuinely interested in your thoughts on this!)

      Yes, I totally agree with the need for a regulatory system to hold doctors accountable for their decisions in prescribing one medication over another. I just wonder at what level of government (if any) such a system could be implemented at… Would it be through the local/state government? Or should it be a national surveillance-like system?

  5. Hello Yuki,
    I think that, as people have said before, The Second Model List of Essential drugs did clarify that if a drug wasn’t on the list, that doesn’t necessarily mean that it’s “inessential.” I still think that when people don’t see something on a list or in the same category as other ‘important’ things, it puts that thing on a different level and they view it in a different way. There is still the problem that the list was created by developed nations for developing nations, which gives the assumption that developed nations are doing everything correct and need to help the developing nations (which is not true). If the list was created by developing countries for developing countries, or even by geographic region, I think this would be more effective.

    As for the wonderful point you made about the relationship between doctors and pharmaceutical companies, I think it’s a tough road to walk. I was wondering if you could clarify what “life-saving advancements” means in this context? Though I don’t think pharmaceutical companies are all bad, I think have relationships between pharmaceutical companies and individual doctors could be dangerous to the health and stress of the doctor’s patient. If someone has expensive medicine to pay for that’s caused by this relationship, it puts a higher burden on them which can cause other health problems. I think we need to look at what a “happy medium” could be if there was one, and what are the consequences, good or bad, for the patient, doctor, and pharmaceutical company.

    1. Hey Katherine,

      I definitely agree that even with the clarification on the second list of essential medicines, there is still the implication that medicines not listed are non-essential. And like others have mentioned in the comments, the fact that developed nations are deciding what the essential medicines are, poses an ethical problem. I like the idea of each region making its own list of essential medications, since that would take into account the community’s perceptions of health and priorities in terms of what is the greatest disease burden from the perspective of the community members themselves.

      By “life-saving advancements,” I think Dr. Rosenbaum was referring to the potential for improvements in medications or advancements in knowledge about health that could come out of these physician and pharmaceutical industry collaborations. Yes, of course, prescription medications can be very costly, especially for people without health insurance, so there is always the possibility that the doctor-industry collaboration could harm the patient rather than help him/her.

  6. Hi Yuki,

    Your definitions of the term “essential” and analysis of pharmaceutical companies gave me a greater understanding of all the different facets of the industry, and I like that you were also able to tie in the topic of the tobacco industry from earlier in the class. I agree that there is a fundamental problem with creating this list, since it averts the focus of pharmaceutical companies from more exploratory development of drugs to reducing the cost of generic drugs. It is difficult to determine if this is good or bad, and I don’t think it is so black and white since this benefits some, but definitely hurts others. The intention of the list is to ensure more affordable general drugs, and though it may accomplish this, prices of other drugs go up. Can something be called “good” if it still hurts people? The Second Model may address the issues of the initial list, but addressing an issue is not necessarily solving it.

    The “drug dumping” as discussed by Greene is a huge issue, and it is almost as if companies are manipulating and capitalizing on knowledge–or lack of it. Those who have the knowledge and ability to help others should never misuse their “power”. Perhaps monetary incentive should be used for safe, effective drugs instead of unproven treatments, but the race for intellectual property rights is unfortunately a large motivational force for progress. Thus the implementation of stronger regulation on the release of drugs could balance the push for new drugs and their safety.

    1. Hey Thu,

      I agree with you that, like with many concepts we’ve talked about in class regarding global health interventions, this is not a black-and-white issue. While the list does help in highlighting the most commonly used and (supposedly) most effective medications, it has its flaws, as pointed out in previous comments above (e.g., the ethics of developed nations creating the list for developing nations).

      I like your idea of placing more strict regulation on the approval and release of drugs to the public. However, in the US, questions have been raised regarding the effectiveness of US Food and Drug Administration (FDA) approval of new medications. A Harvard study in the Journal of Law, Medicine and Ethics in 2013 showed that about 90% of drugs approved by the FDA over the last 30 years have little to no advantages when compared to drugs that were already on the market. The article also reports striking statistics about the large number of people who suffer from severe prescription drug-related complications, including insomnia, digestive problems, and even death. On top of that, there is rising suspicion of corruption between pharmaceuticals and the FDA. Such a collaboration between big pharma companies and the FDA can lead to drugs being approved more quickly and with less evidence for their effectiveness. I just wanted to bring this up as something to think about regarding tighter regulations on drug approval.

      http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2298140

  7. Hi Yuki! Thanks for your informative post. I actually had no idea that a system like ATMI existed and suggested something similar in another blog post comment that I made. I just visited their website and was interested in learning just how much of an incentive the ranking provides for companies who aren’t doing as well in the realm of delivering affordable drugs. To me, it seems that for such a system to be successful in motivating pharmaceutical companies, it would have really assure economic advantage. This might look like developed countries only buying from companies that deliver effective, low-cost drugs to poor populations.

    Anyway, I’m also really glad that you brought up the issue of the doctor-industry relationship. It’s a rather sneaky business that not a lot of people talk about, but something that’s definitely going on. If we were to assume that all doctors were compassionate people that always had the best interests and contexts of their patients in mind, then perhaps the idea of being financially compensated for prescribing certain drugs can be justified. Of course, that’s not the ideal world in which we live. Although I am sure doctors are held to to a standard (hippocratic oath, no intentional harm of patient etc.), the realm of pharmaceuticals becomes gray territory in which doctors are not entirely regulated. In this situation, being compensated according to the prescription of a certain drug could easily become insidious, whether unintentional or not.

    Although it might be oversimplifying the dynamics of the situation, I would suggest that doing away with any financial compensation would help abate situations in which doctors may cause harm to their patients through prescription of “tempting” drugs. If the decision to prescribe came without monetary gain, than the decision should hopefully arise solely from the doctor’s knowledge and expertise of the illness in question and the confidence they have in the drug. At the same time, doing away with financial compensation would allow pharmaceutical companies and doctors to continue interacting in ways that might spur life-saving advancements through research.

    1. Hey Lilian,

      I like the idea of giving pharmaceutical companies a more economic incentive for making their drugs more affordable and accessible to anyone across the globe. However, I also feel that placing an economic incentive takes away from the humanitarian rationale of marketing effective medications at affordable costs. Ideally, pharma companies should be motivated to provide their products to developing nations at low prices (or for free) based on corporate social responsibility and the desire to benefit society. It would also be difficult to implement economic incentives such as the one you mentioned (developing countries only buying products from companies that sell their medications at affordable costs). How would you envision implementing such economic incentives?

      I do agree with your point that eliminating the financial compensation for physicians who prescribe certain medications would also eliminate the bias that could potentially harm patients. In that case, the pharmaceutical-physician collaboration can still contribute to society with scientific advancements in medicine without the problem of corruption.

  8. Hi Yuki,
    Great post! I really like how you draw ties between drug-dumping in the pharmaceutical industry and the push of the tobacco industry outside the US in the 1960s. That is a very striking, and scary, comparison.
    Dr. Lisa Rosenbaum’s point that you bring up is fascinating to me. She makes a good point that collaborations between physicians and pharmaceutical companies could lead to innovations that might not be possible without the combined expertise of both doctors and pharmacologists. However, I suppose the pitfall of doctors suspiciously prescribing a drug manufactured by a collaborating company is unavoidable. I wonder if there might be away for physicians and pharmaceutical companies to collaborate solely for the purpose of developing a needed drug, and not necessarily only for a profit. Perhaps that is too idealistic of me. In her article, Rosenbaum discusses trust—patients will take off their clothes with their physician, and share secrets and bad habits, but won’t necessarily trust that their physician is not collaborating with a pharmaceutical industry. Maybe there needs to be more transparency to solve this conundrum; maybe the Sunshine Act part of the ACA will help.

    1. Hey Lindsay,

      That’s an interesting point you bring up – that perhaps doctors and pharmaceutical companies can work together to develop new, more effective medications (e.g., medications with less side effects or that can be used to treat multi-drug resistant diseases). Lilian suggested a similar change in the collaboration in her post above. I think it would definitely make sense to eliminate the financial compensation for prescribing certain drugs. However, one must take into consideration that pharmaceuticals are businesses trying to make a profit, and having physicians on their side would help in that endeavor (since they would be more likely to prescribe those particular companies’ medications). So unfortunately, it may not be very feasible to completely eliminate the economic incentives behind the dharma-physician collaboration. I think the Sunshine Act does help in increasing transparency on this issue, but I think that the patients’ distrust of the collaboration, like you mentioned, shows that there is more work to be done.

      Leah brought up a point earlier that there should be a regulatory system to monitor the decisions doctors make when prescribing one medication over another, especially when the doctor has economic ties with a pharmaceutical company. In such a system, a doctor would be held accountable for their decisions in that they would have to explain their reasoning for choosing a certain drug. I just wonder at what level of government (if any) such a system would be implemented – local/state/national. Or would it be handled by an organization completely separate from government?

  9. Hi Yuki,
    I enjoyed reading your post on the dangers on pharmaceutical industry and doctor collaboration. I think that for the most part, the alliances between physician and pharmaceutical companies are extremely dangerous, especially because before anything else, a pharmaceutical company is a company of economic profit. Unlike physicians it is not their job to help people, but to make a profit. When financial incentives become masked with humanitarian intentions, unintended consequences are almost inevitable. When doctors partner with companies to promote a drug, the repercussions of this drug are not considered. For instance, if a certain drug (like an antidepressant) can cause someone to get hooked on it and need it, even when their symptoms are gone, then what will happen when this person is put off of the medication? When the incentive is to push sales of a drug, instead of improving overall health, the detriments caused by the drug are ignored.

    1. Hello Silvia,

      You raise a good point that there may be unintended consequences, such as addiction to antidepressants, when physicians partner with for-profit pharmaceutical companies.
      I think it’s important to keep in mind, though, that not all pharmaceutical companies are purely focused on profit. For instance, Merck and Pfizer, two of the largest pharmaceutical companies in the world, have led global health initiatives to increase access to medications in developing nations. Pfizer ran a “Mobilize Against Malaria” campaign for five years, providing treatment and care for malaria patients in sub-Saharan African countries most affected by malaria – Ghana, Kenya, and Senegal. Merck has a donation program in which it provides medication for onchocerciasis (river blindness) and lymphatic filariasis in countries of Africa where the two diseases co-occur. Some pharmaceutical companies have incorporated social responsibility into their missions, although making profits may still be their priority at the end of the day.

      http://www.pfizer.com/responsibility/global_health/pfizer_malaria_partnership
      http://www.merckresponsibility.com/access-to-health/key-initiatives/merck-mectizan-donation-program/

  10. Thank you for your post Yuki,

    It was a good idea to name the issues with the essential drug list, as you pointed out in your post, in the Second Model List of Essential Drugs, namely that the problem with making a list is that certain drugs are bound to be left out. I agree with you that the making of this list has put a priority on medications that might benefit the most people, leaving out those drugs that are essential to a minority of the population. I don’t believe just naming this issue is an adequate fix. I believe that the list should be expanded, and of course this also has its own problems, but at the very least an attempt should be made to name all drugs that are essential to someone as essential to the population.
    I believe that doctor-industry collaboration is essential in treating a population because the industry produces the drugs that are available for the doctors to prescribe. This said, I believe it is totally inappropriate to be offered financial incentives for prescribing certain medications. If the goal of prescribing a drug is for clinical studies then the drug should be prescribed for the advancement of knowledge, never for money. If the goal is just to help someone get better then the drug should be prescribed solely because it will help them get better, never for money.

  11. Hey Steven,

    Thanks for your comment! Could you please elaborate in what way you think the essential medicines list should be expanded? For example, who do you think should be in charge of making additions to the list, and for what group of people would the list be applicable to? I feel that a list of essential medicines created by the WHO alone would not be specific enough for the list to be applicable to both developing and developed nations. And even within the category of developed/developing nations, there are major differences in terms of what health goals are prioritized. One community/country may view HIV/AIDS as the most important infectious disease to be treated, whereas another community/country may place its priority on mental health. Each community/country will also have varying degrees of value placed on health in general, so how can we account for all these differences? Should each community/country have its own list, created in collaboration with community leaders or state government?

    Yes, I agree with you that the doctor-pharmaceutical collaboration has its benefits of advancing knowledge in medicine, and I, too, feel that financial compensation for prescribing certain drugs is not appropriate. However, outlawing such acts may just drive the compensation for prescription of certain drugs underground (forming a sort of “black market”). Do you think there’s a compromise that could be made here? Leah and I were thinking about a system of supervision where a doctor is required to give explanations for prescribing one drug over another similar drug made by a different company. I think it would be monitored by state or local-level government, rather than the national government. I’m looking forward to hearing your views on this!

  12. Hey Yuki!

    Thank you for your very informative and thought provoking post. I also think you brought up some great points and questions in your reply to comments.
    I, like Lillian, was unaware tat there was a system in place like the ATMI. I think it really is key in providing incentives for corporate responsibility. Although there are definitely parallels between the big pharmaceutical companies and tobacco companies, with more experience in how to address this problem I like to think it is possible to make a difference before it reaches levels similar to tobacco. I think pharma companies have started to incorporate models of corporate responsibility and have some sort of dedication to global health, even if a cynic may argue it is only out of self interest.

    I, also really enjoyed your discussion of the relationship between doctors and pharmaceutical companies. I agree with Dr. Rosenbaum that innovation often requires different people’s expertise and that collaboration with physicians may result in furthering in the advancement of knowledge. I, however, have a hard time not focusing on the conflict of interest when there is large sums of money involved. One of the most important element of the physician-patient relationship is trust. A doctor has to trust his or her patient to give all the necessary health history and information, which is sometimes uncomfortable. The patient in turn need to trust the doctor to respect their confidentiality as well as do everything in their best interest. When there is a drug that gives the doctor money for prescribing it, this takes away an element of trust from this relationship. I definitely agree with Lindsay that there is an aspect of trust is important in discussing this topic. I think the Sunshine Act can be very helpful in terms of this, but I also think it needs to be implemented in a way that will actually make a meaningful difference. I think it needs to be disclosed in a way that patients who go see a certain doctor are well aware of any endorsements that that doctor may have. I actually shadowed several Primary care physicians this summer and one of them talked to me about this issue, he told me how he believed that when he took his oath, he needed to put his patients above personal gain and he said he would be unable to do with pharmaceutical endorsements. He showed me how to access the public information records of contribution pharmaceutical companies make to doctors and hospital. It was on a simple to get to, but before this day I had now idea this was occurring and I am sure many patients remain unaware even if is “public”. I don’t want discount medical advances that could arise from collaboration, but I think it needs to be well though out to prevent conflicts of interest. Possibly if the doctor was not rewarded for prescribing the medication, but simply for helping with the research this could minimize the problem.

    1. Hey Yilena,

      Thank you for your comment! I also have hopes that changes can be made to avoid the possibility of pharmaceuticals turning out to be like the tobacco companies, and yes, some pharmaceuticals have definitely incorporated tenets of corporate responsibility into their mission statements and have donated medications to populations that may otherwise not be able to afford them.

      I also am not in favor of doctors being compensated for promoting certain drugs, and I think there can still be substantial collaboration between doctors and pharmaceutical companies without the compensation. If a doctor were to accept payment for prescribing certain drugs, then I believe the doctor should be upfront with the patient and admit that he is endorsing the medication due to doctor-pharmaceutical ties. I think the doctor should also then explain to the patient why he is choosing to prescribe this medication over other similar medications made by other companies. This is not a solution to the issue of doctor-industry collaborations that involve compensation, but it is a step toward preserving the fundamental trust between the doctor and patient that you mentioned.

      I’m really glad to hear about the physician you shadowed and how willing he was to show you the public database on doctors and hospitals receiving compensation from pharmaceuticals. I am in agreement with you that most of the general public is probably unaware that the information is publicly accessible.

      You bring up a good point that doctors can be rewarded just for helping with research, and I am wondering whether you mean research through clinical trials. If so, it also depends on what you mean by “helping,” but I think that rewarding doctors for helping with clinical trials can also get sticky, since it still comes back to the same issue of doctors prescribing certain medications to patients to see whether the medication works as intended. In clinical trials, patients are informed about the purpose of the medication and its possible side effects, as well as the fact that they are on a trial to see if the medication is effective. However, I still think that the rewards (which would most likely be monetary) would still bias doctors to using one new drug over another company’s new drug. It may be difficult to try to eliminate bias completely in any situation, but I believe there could be meaningful and productive doctor-industry collaboration without the transfer of money, as doctors and pharmaceuticals are (supposedly) both trying to reach the same overall goal of reducing burden of disease and illness by promoting health for humanity.

      I don’t mean to sound overly cynical in my blog post or comments, but I am sometimes suspicious of businesses (i.e., pharmaceuticals in this case) trying to make money while working towards curing illnesses, especially with the recent cases of Turing Pharmaceuticals and other drug companies raising prices on their medications.

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