MARKETING HEALTH THE MULTINATIONAL WAY
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MARKETING HEALTH
THE MULTINATIONAL WAY - extracted text
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MARKETING HEALTH
THE MULTINATIONAL WAY
MARKETING HEALTH
The Multinational Way
Vanaja Ramprasad
Gopal Dabade
Drug Action Forum - Karnataka
MARKETING HEALTH
The Multinational Way
Dr. Vanaja Ramprasad
Dr. Gopal Dabade
©DAF-K
First Printing 1991
Published by
Drug Action Forum - Karnataka
57, 'Soni', Tejaswinagar,
Dharwar - 580 002
Designed by Design for Fun & Money, Bangalore
Printed at W.Q. Judge Press, Bangalore.
DTP Services: WORDMAKERS
CONTENTS
V
Foreword............................. ........................................................ 5
Introduction.................................................................................7
1.
Drug Situation In India - An Overview..................................... 9
2.
Political Economy of Drug Production And
Distribution................................................................................12
3.
Tall Claims and Little-known Facts.........................................17
- Ayurvedic Hard Sell........................................................ 28
- So Much For So Little Case of Weaning Foods and Health Foods.................... 31
4.
Issues Threatening a Rational Drug Policy............................. 34
5.
Is it True ?
............................................................... ....36
FOREWORD
This booklet entitled Marketing Health - The Multinational Way
is a worthwhile and laudable attempt to keep all citizens better
informed about the marketing of inappropriate and unessential
drugs. Some concerned citizens in various parts of India have
formed groups to be vigilant about this. The Drug Action Forum in
Karnataka (DAFK) is such a forum. This booklet is being brought
out by them.
The activities of drug companies in India need to be
scrutinised much more than at present, mainly because they are
very much controlled by the Multinationals. This has been
highlighted in various international meetings such as the UNCTAD
at Colombo and the United Nations itself. They have gone to the
extent of charging the developed nations with perpetuating 'Drug
Colonialism' in the so-called third World. "Mahler,the Director
General of WHO, has even cautioned the governments in the
developing nations about the attempts of the multinational drug
corporations to market irrational drug formulations which are
often discontinued in their parent countries." (N.I.Joseph :
'Multinationals in the Drug Industry7 in Social Scientist, p. 78).
Estes Kefauver in his book In a Few Hands had no hesitation in
severely criticising the giant drug companies like Pfizer, Cynamid
and Smith Kline and French Ltd. (SKF) for their malpractices and
exploitative activities.
The Hathi Committee after some studies concluded that the
foreign companies have established a vice-like hold in India
through their affiliates in India. The total turnover of more then
2800 pharmaceutical houses in India 'both Foreign and Indian is
Rs.700 crores (Ref : Myth & Reality of Drug-Industry by the
Standing Committee of the National Convention on Economic
Independence and Perspective of Drug Industry, New Delhi).
It is also to be realised that the testing of new products on
human populations is governed by the Helsinki Declaration. This
was published by the World Medical Association in 1964 ; and this
took over from the Nuremberg Code which was developed at the
5
end of World War II. All these require voluntary informed consent
from the human subject. When medicines are tested in the Third
World countries, it is surmised that it is more difficult to be
absolutely sure of the level of informed consent given by the
subjects.
These and many other aspects made the Hathi Committee
suggest that the Drug Industry should be nationalised. But this by
itself will be insufficient to solve the unethical practices of the
powerful multinationals. A concerted effort to educate the public
(the consumer), is the crying need.
This booklet is an attempt at initiating such a process.
V.BENJAMIN
Professor of Community Health (Retd)
Christan Medical College, Vellore.
President, Drug Action Forum-Karnataka
6
INTRODUCTION
i
■
--------------------------------------------------------------------------------------The staggering poverty statistics and prevalence of diseases
and malnutrition are a sad commentary on the development pace
of the third world countries. More than 800 million people in the
developing world live in conditions of squalor, abject poverty
deprived of basic nutrition.
In India one-third of total deaths among children are below
the age of five years. Infant mortality rate is still hovering around
100 per thousand live births. The prevalence of malnutrition
particularly the first degree and second degree continue to be
exceptionally high and is only the tip of the iceberg.
Communicable and other preventable diseases have still to be
brought under control. Lack of safe drinking water, the inhuman
conditions of living present in the urban slums, poverty and
ignorance are still posing a challenge to the administrators.
l
The distribution pattern of the sophisticated medical services
are skewed and all concentrate in the urban areas. India spends a
very small percent of GNP for its health care. Although drugs
constitute essential tools for medical service, it is disturbing to
note that the focus of the pharmaceutical industries has been
directed towards industrial and trade development. As a result the
industry has pushed
up production and promotion of
non-essential drugs and nutritive supplements. A host of
pharmaceutical products are produced and promoted with the
claim of correcting situations which actually arise out of
undemutrition and poverty and thus the market is flooded with
costly pre digested protein foods, anabolic steroids, iron,
glycerophosphates, calcium, vitamins, appetite stimulants,
enzymes and now ayurvedic products. The layman, guided by the
doctor's advice and the promotional literature put out by the
pharmaceuticals, is the consumer of all such products.
Educating the consumer is one of the main objectives of the
Drug Action Forum Karnataka. The monograph on unessential
drugs like vitamins and tonics is intended to draw attention to
the use/misuse of all products under this category. There are two
7
reasons for this. All the products included in this category flood
the market and it is only the poor who need good nourishment but
in a different form for they can ill afford this. Secondly in the case
of those who can afford it, very often it amounts to misuse.
Chapter 1 gives "an overview" of the drug situation in the
country.
The drug policy and production is contained within a certain
frame of political economy that controls the market. Chapter 2
highlights the main issue of patenting of the drug and its impact on
the Third World.
In chapter 3 actual examples of the promotional literature are
carefully chosen to anlyse the tall claims. Little known facts of
marketing techniques are discussed and highlighted.
Talking of unessential drugs, it is only one of the many issues
that need to be highlighted. What are these other concerns? The
freely available banned and bannable drugs; The problem of
hazardous drugs; the irrational formulations such as cough syrups
; and the multivarious pain killers. This is highlighted in chpter 4.
How can we make the best use of this book ? The lay person
has many questions that need to be answered. While planning
this monograph and discussing it with many interested persons
we were asked if we were not producing more quacks by making
available information to the common man ? Why is'nt the
government banning the unessential drugs ? Don't Doctors know
about all this ? Don't we need vitamin supplements to combat
malnutrition ?.
The last chapter gives a view point answering some of these
questions on vitamins, tonics, nutritive supplements and
Ayurvedic tonics. We acknowledge the support given to us by the
members of the forum.
8
DRUG SITUATION IN INDIA AN OVERVIEW
Since India's independence in 1947, the drug industry has
grown considerably. UNIDO has acknowledged th^t the Indian
drug industry is capable of self-sustenance. These achievements
are no doubt phenomenal. But let us take a closer look as to how
much it has mattered to the Indian pepole's health. In our country
every year 40,000 children become blind because of Vitamin-A
deficiency, which is preventable and yet we do not produce
adequate Vitamin-A. We do not produce adequate drugs for T.B,
Malaria, anemia and leprosy which is our need. There is no doubt
that the production of unessential drugs is extremely profitable
resulting in a lopsided irrational drug situation. Seeing this
situation, Haathi Committee was set up in the year 1975 to look
into the drug industry and give recommendations. Justice
Jaisukhalal Haathi, who headed the committee had some well
considered recofnmendations to make.1
Some of them are -
1. Brand names should be abolished and generic names for
drugs to be introduced.
1
Dr. Iqbal - A Decade after Hathi Committee published by KSSP.
9
2. Journals to be published to keep medical profession wellinformed about drugs and to popularise generic names.
3. Effective quality control of drugs.
4. Irrational drug combinations to be eliminated.
5. Indian National Formulary to be up dated.
6. The 117 essential medicines identified by the committee to
be made available at fair and reasonable price to the consumer.
7. The ICMR to concentrate its attention
newer drugs for tropical diseases.
on discovery of
8. Multinational pharmaceutical companies to be nationalised.
Ironically today the recommandations of the Haathi Committee
have virtually been forgotten in India though the same Haathi
Committee report was taken up by Bangladesh and implemented
in 1982. Even today Bangladesh continues to have a successful
rational drug policy with very few setbacks.
WHO has drawn a list of 250 essential drugs, which would
meet the major needs of most illnesses in a community any where
in the world. Haathi Committee had recommended a list of 117
essential drugs for our country.
Today the Indian drug industry produces about 75,000
formulations most of which are unessential or hazardous and
have been banned in several other countries. Tonics and enzymes
are not essential and form a large bulk of the production.
Hazardous drugs banned or restricted for use in several other
countries continue to be sold in the market. For example, Analgin
which is banned in USA and known to produce a fatal life
threatening blood disorder is very easily available in our country.
Another much commonly misused pain-killer is phenylbutazone.
The list of such hazardous drugs is of serious concern, (for further
reading refer AlDAN's - Banned and Bannable drugs)
The concept of generic names has been completely forgotten
in our country, though this was a major recommendation of Haathi
Committee. There is a distinct advantage both for patients and
doctors if generic names arc used. But drug companies insist on
brand names, because it is profitable to market in brand names!
10
India's Drug Policy is framed by Ministry of Petroleum and
Chemicals and the Health Ministry has little to do with it. Is'nt this
unfortunate? Again our Drug Policy is more a pricing policy and
does not look into other issues like banning of Hazardous drugs,
quality control and drug distribution, which are all important for
rational drug use.
Last but not the least, now the drug companies have jumped into
production of Ayurvedic drugs and other non-allopathic drug
production which are not regulated at all and the drug companies have
a free hand to make more profit. This is a dangerous trend indeed.
The question is "should the drug industry be people-oriented
or profit- oriented?"
POLITICAL ECONOMY OF
DRUG PRODUCTION AND
DISTRIBUTION
At the simplest level political economy of drug production
and distribution
examines the social organisation of the
production, exchange, distribution and consumption of medicines.
Research and development of drugs
are initiated at the
international level to capture markets of the Third World. It has
deluged the health care
TURNING THE SCREWS
system
with
drugs,
'THE UNITED STATES estimates
equipments and techno
that
it suffers an annual loss of $ 50
logy and projected growth
and
profits.
Many billion from patent violations across
world. This is no small amount for
developing
countries athecountry
running an annual trade
spend a high proportion of deficit of $ 150 billion. So it is not
their health budget on surprising that the US has been working
drugs. Majority of their on a worldwide agreement that would
populations have limited give more protection to US products.
access to those drugs that Senior US officials are currently in
are essential. This is India to try to convince the
because the country does Government to agree to a more rigorous
not produce the kind of protection of "intellectual property".
The violation of US patents is not very
drugs that are needed but significant in India; the phenomenon is
on
the
other
hand more common in East Asia and Latin
continues to be flooded by America. But India is one of the
a large number of costly developing countries that until recently
and wasteful drugs meant has been in the forefront of opposition
for minor illnesses of the to the international convention on
rich and well to do. This patents. Cont..
brings us to the question for whose needs are drugs produced?
The total output of the industry increased hundred fold from
Rs. 100 million in 1947 to Rs.10,500/- million in 78-79.2 The skewed
pattern of drug production is in keeping with the inequitious social
2
12.
Delhi Science Forum. “Drug Industry and the Indian People".
structure. It has been observed that out of a total production of Rs.
700/- crores in the mid seventies 25% was taken away by vitamins,
Tonics, health restoratives and enzyme digestives. Only 20 percent
was covered by antibiotics and a meagre 1.4 per cent by
anti-tuberculosis drugs.
The basic causes for this are the inexorable laws and
tendencies of a capitalist economy. The Pharmaceutical industry in
India has been dominated by the giant foreign companies. Since
most of the research in Pharmaceuticals is done by giant
multinationals and since pharmaceutical industry is protected by
patent laws, 90 precent of patents in the industry are also held by
these foreign controlled companies. Charles Medawar of Health
Action International points out the significance of the multinational
domination. Even back in
The issue is a difficult one to
1980 "World sales of each
resolve. The considerable expenditure
of the 15 largest companies
that
goes
into
research
and
( between US $1 and 2.3
development requires that the inventor
billion) exceeded the gross
of a product or process should be given
national product of many
some protection so that he can earn a
Third
World countries".
reasonable return.
However, such
With such a high level of
protection invariably also leads to a
corporate concentration; it
higher price, which, especially in an
area means a conflict between private
comes as no surprise that
gain and public interest. The issue is
the Third World
is
even more complicated in developing
supplied mainly western
countries whose past experience has
drugs. The best selling of
been that less than 5 percent of patents
them are vitamins, tonics,
granted to foreign companies have been
cough
syrups, and oral
exploited for domestic production.
contraceptives.
Clearly, patents here are used to
pre-empt domestic production, the
patentee preferring to meet demand
through imports. Cont...
Less than ten years
after the preparation of an
essential drug list by
WHO which identified 200 preparations adequate to meet 90 % of
the medical requirements of any country, the proliferation of drugs
in the market reached new heights. It was estimated that for the
700 most important chemical compounds circulating in the
worlds drug sector there are over 50,000 brand names averaging 70
different names per compound.
on
Pharmaceutical multinationals spend 13-15% of their turnover
research and development, compared to the 24% on
13
marketing. With small modifications, old formulations in new
packaging are sold as
revolutionary drugs. In India 52
multinationals spent 33% of their turnover on sales promotion.
Impact of the sales force on the medical profession is so telling that
a recent study in the UK showed that six out of ten British
Physicians prescribe a product solely on the basis of a drug
representative's recommendations.3
PATENTS AND MEDICAL ETHICS
A patent is a right granted by a government to inventors
to exclude others from imitating, manufacturing , using or
selling a patented process or product for commercial use for a
period of usually 17-20 years. Patents can have major impact
on the health care system of the country. Patents can
determine access
to technology, prices, availability of
alternative medicines in their generic name etc., A study done
by UNIDO stressed that ’’The strongest point which permits
the domination of transational pharmaceutical corporations is
rooted in the patent and brand name system. As laid out in the
Paris convention, patents on drugs grant the patent holders not
only the monopoly over production but also exclusive rights to
import the product.
In the Third World countries, product protection for drugs
simply eliminates national opportunity to innovate economic
alternatives.
3
14
Charles Medhawar. Social Audit - Insult or Injury? An enquiry into the Marketing
and advertising of British Food and Drug product.
It is on this issue that developing
countries have on the whole been
opposed
to
the
existing Paris
Convention on patents. The convention
was first signed in 1893, has been
revised only six times since then, and,
while supposedly according equality to
all signatories, in actual practice
discriminates heavily in favour of
countries holding the most patents. It
is not that the developing countries do
not have any patent laws. These laws
are however, less stringent than those
of the US and Western Europe and
encourage local production rather than
imports.
Under US pressure, intellectual
property (along with services) was put
on the agenda of the Uruguay Round of
trade discussions. In the meanwhile,
however, the US has continued to force
individual countries to provide stricter
protection to foreign products and
processes. Under the threat of trade
retaliation, this has worked to some
extent in East Asia. The pressure in
now being put on India. The US
strategy appears to be to make a new
international
agreement
a
more
attainable proposition through pressure
on individual countries. The terms of
this new agreement will ultimately
depend as much on a common Third
World Platform as on the intensity of
US pressure. (Deccan Herald, July 30,
1988.
4
India after a great
deal of tussle with the
multinational
Corpora
tions, which own 85
percent
of the patent
registered in the world,
enacted its patent law in
1970. The essence of the
law is that it provides a
solid and viable basis for
Indian R and D to develop
technologies
for
substituting the import of
patented products and
prevent their unhindered
access to the Indian
market.
This also explains the
frantic
lobbying
by
international drug firms
to drag India into the
Paris
convention
of
patents. The implications
of India joining the paris
convention which is over
a
hundred years old,
agreed
by
powerful
nations, is far reaching.
When a poor patient
pleads for survival and his
disease can be cured by a
life saving drug, it is
diabolical to deny him
that medicine on account
of state policy which vests
a patented monopoly for
its manufacturer, says the
human rights proponent.4
V.Krishan Iyer. "Drug Policy and Right to Health " ,The Times of India, Nov 27,1986.
15
TALL CLAIMS - LITTLE-KNOWN
FACTS
Some of the irrational practices in formulating and promoting
products under the category of vitamins, minerals, tonics, enzymes,
and appetite stimulants cause concern and raise the following
questions:
—
Is there is a uniformity in the dosages recommended?
—
Is there an authority that lays down the criteria for
dosages?
—
How are these recommendations made? What are they
based on?
—
Is there a check on the quantities claimed to be present in
the formulations?
—
How true/scientific are the claims made in the
promotional literature?
—
Are the combinations of vitamins and minerals rational?
—
Are there contraindications that are played down?
—
How essential are these products?
—
Can we market health through the proliferation of those
products?
We have attempted looking for answers to these questions
taking some illustrations. Many products that fall into this category
do not have satisfactory answers. The list becomes an endless one.
The economics of producing and consuming tonics has been
analysed by Kamala S. Jaya Rao in her article 'Tonics - How Much
an Economic Waste in In Search of Diagnosis.
The thrust here, is in erasing the aura around tonics and
vitamins projected by marketing them. The examples cited are
illustrative and not exclusive or exhaustive.
16
The pharmaceutical industry has a disproportionate influence
on consumption through advertising and sales promotion (through
medical representatives) and through confusing profusion of
brand-name products. Doctors' prescriptions are rife with tonics.
Unlike other commodities, the position of the pharmaceutical
product is targeted towards the medical profession. Sophisticated
methods of promoting products through the media,detail men and
various gimmicks are practised. The study of human behaviour
forms an important aspect of the strategies adopted by advertising
firms in general and pharmaceutical firms in particular.
An excellent example of the preparation of sales force is the
speech delivered by the marketing manager of Glaxo India Ltd
while addressing medical representatives. This appears in the
company's promotional booklet (Jan-Feb> 1978) and states : "That
you have achieved this without the help of any major antibiotics is
proof of your ability to generate prescription support. Doctors
today are prescribing more and more Glaxo products due to your
effective detailinig from the folder. Modem teaching in consumer
behaviour emphasizes the point that in the absence of strong
reinforcement, brand shift takes place. Reinforcement must be
17
in the form of repeated stimuli. Please remember the primary
stimulus is communication. Gifts and samples are only cues.
Secondary stimuli will work only if the primary stimulus is
strong;this means complete detailing from the folder.
J.S. Majumdar and Samir Kumar Das5 report that an
examination of the detailing folders,booklets,medical literature etc.,
from eleven major multinationals revealed the nature of the double
standards of marketing and sales promotion adopted by MultiNational Corporations (MNCs) in their countries of origin and
Third World countries.lt was also observed that their own
voluntary code of marketing practices were violated to achieve
their targets.
Marketing experts say, "There must be continuous plumbing
of deep-seated, even illogical but gradually changing social habits
before marketing break through. Creating a new market means
changing a way of life." Advertising is one of the main tools used
to achieve such a change.
Unacceptable Standards of Advertising
In respect of printed promotional material, the International.
Federation of Pharmaceutical Manufacturers Association's
(IFPMA) code states, Scientific and technical information shall fully
disclose the properties of pharmaceutical products as approved in
the country in question, based on current scientific knowledge
including:
— The active ingredients, using the approved names where
such names exist.
At least one approved indication for use together with
dosage and method of use.
A succinct statement of the side effects, precautions and
contra-indications"
On close examination of the promotional literature, it could be
alleged that journals and textbooks are misquoted or quoted out of
context resulting in false and confused impressions.
5 m ■Maiumdar & Samir Kumar Das, in 'Unfair practices in Marketing Adopted by
national Drug Firms in India' (Drug industry and the Indian people)
18
EVION
— One example is E
Merck's
claims on Evion
Vitamin E. Acetate l.P
600: "Vitamin E is located
(L.- Tocopherol acetate I.P)
primarily in the membrane
portion of the cell. A
number of enzymatic and
In direct contrast, a well-reputed
non-enzymatic free radical
medical text, Goodman and Gilman's
generating reactions occur
The Pharmacological Basis of Therapeutics
in the cells. Vitamin E
states that the amount of Vitamin E
and unsaturated fatty acids in the diet
functions as an invivo
affect
reproduction
and
that
anti-oxidant that protects
antioxidants incorporated into the diet
tissue lipids from free
can completely obviate the need for
radical attack.
It is
Vitamin E for normal growth and
proposed that Vitamin E is
reproduction in the rat.
Thus, the
an effective scavenger of
essential nature of Vitamin E in
pregnancy is unclear on the basis of membrane radicals. Some
have proposed free radical
animal studies. "Vitamin E has been
induced cellular damage
used in human beings for the treatment
and
accumulation
of
of recurrent abortion and for sterility.
It has also been used in disorders of
lipofuscin as the possible
menstruation,
vaginitis
and
mechanism of the aging
menopausal symptoms. In spite of the
process. Hence it is
early, enthusiastic usage of Vitamin E,
suggested
that
there is no conclusive evidence that the
administration of Vitamin
vitamin is beneficial."
E may slow down the
cellular changes. There is
Goodman and Gilman
also substantial evidence
of the utility of Vitamin E in the care of premature infants and
children with malabsorbtion. Animal studies have shown
myopathy and reproductive abnormalities in Vitamin E deficiency
studies."
Goodman and Gilman6 also say: "the lack of efficiency of
Vitamin E in the treatment to those diseases that bear resemblance
of Vitamin E deficiency in animals, like recurrent abortion,
progressive muscular dystrophy and cardio-vascular diseases have been discussed. These by no means are the only disorders in
which Vitamin E therapy has been studied. The list extends from
minor skin aliments to schizophrenia. With possible exception of its
potential value in treating the anaemias associated with extreme
protein calorie malnutrition or pre maturity,results with
6
Goodman and Gilman, "Phamacological Basis of Therapeutics."
19
alphatocopherol have in general been so disappointing that the con
clusion seems justified that at present there is no persuasive evidence
that Vitamin E has any therapeutic use." These apparent contradic
tions leave the user confused and helpless.
With regard to "intermit
tent claudication" Martindale
notes that Vitamin E was not
proven to be of value, and this is
yet another instance of conflicting
claims.
E. . Merck
has
also
recommended 400 mg for nocturnal
muscle cramps and intermittent
claudication, 600 mg for fibrocystic
breast diseases and atherosclerosis.
INDICATIONS
• Mental aqj rexias of childhood
• Post-infective anorexia#
’ Deficiency anorexias
' Anorexia of nursing infanta
• Retarded growth and development
* Anorexia of adults
' Anorexia nervosa
COMPOSITION
Each 5 ml contains:
Cyproheptadine Hydrochloride I.P.
2 mg
Peptone
25 mg
Lysine Hydrochloride U.S.P.
150 mg
In a palatable syrupy base.
DOSAGE.
Children: 2 to 6 years—1 teaspoonful 3 times a day.
Children: 7 to 14 years—i to 2 leaspoonful 3 times a day.
Adults: 2 teaspoonful 3 times a day.
WARNING Son* p«>>on. n*y tM> 0/ow.y wlh lb* linl OOM cl ORAXIN.
■' lh.» b*pp*n». uwy .ncdd nor Orrr. a
O' ooerata m*crun«ry or
•cp>.*ncM raov-nne a-annaM.
PRESENTATION—Bottle Of 100 ml.
Marketed by:
CENTAUR LABORATORIES PVT LTD
Santacruz (East), Bombay 400 029
Advertising Gimmicks
Advertisements create needs by suggesting new and
sometimes absurd or unnecessary uses for products. Sometimes a
side effect of a drug is projected as an indication for its use. For
example, Oraxin syrup is promoted as essential for weight, height and
good appetite. One of the side effects of the main ingredient,
Cyproheptadine, is weight gain. Many drug companies are
promoting it for weight gain, emphasising the side effect into the main
indication. The product is promoted for indiscriminate use even in
children and infants. Other side effects, toxicity, precautions,
contra-indications, etc., are totally absent in the folder. No standard
medical literature recommends the use of the drug for weight gain.
The Promotional litera ture quotes Lancet (197811367) to say the following:
"Cyproheptadine is the first chemically proven appetite stimulant. It has been used
successfully to increase the appetite of underweight patients with pulmonary
tuberculosis and may be of some limited value in the management of anorexia
nervosa. What follows this was more important and yet was excluded from the
promotional literature. "Disturbingly in India Cyproheptadine is promoted as a
general appetite stimulant or tonic"
20
—Periactin is yet another example of an appetite stimulant that
is aggressively promoted "For the growing child who lacks appetite
for the growing child who is underweight "
'
Most independent authorities
PERIACTIN SYRUP
advise against the use of appetite
stimulants. The consultants of the Cyproheptadine
independent U.S. publication hydrochloride 2mg/5ml
"Medical letter" believe that the
promotion of the drug will do more harm than good.7
Periactin has not been promoted as an appetite stimulant in the
USA since 1971 because the U.S Food and Drug administration
considers that there is inadequate information to support this claim".
In 1985 Social Audit - a U.K public interest group started an
international campaign against the promotion of Periactin as an
appetite stimulant with the publication of two anti-advertisement
leaflets. Thanks to the Social Audit-VHAI campaign Merck, Sharp &
Dome (MSD) has ceased to promote Periactin. This is a welcome step
but the company still maintains that appetite stimulation is a "Well
established and medically valid" indication for use. According to a
recent WHO publication, "There is no scientific evidence that drugs
and mixtures that are proposed as appetite stimulants have any effect
on appetite. Therefore these preparations should not be used".
According to the report the dosage of cyproheptadine recommended
for appetite stimulation in children causes a significant suppression
of the release of the growth hormone which may lead to inhibition or
stunting of growth in the children. The long term effect of the drug
on the child's mental development is still uncertain.9
Advertisements can create needs by getting at people's
vulnerable spots - for example, ,rYour child is intelligent but is he
alert?” ask the advertisement for Roche Vitamin Forte.
Advertisements can also create the need through unnecessary
product differentiation and related tactics.
In selecting the advertising messages, foreign firms pay
particular attention to brand names, brand image and product quality
and features.
Firms have taken advantage of the fact that consumers, show
a preference for products with foreign or international brand
names.______________________ _______ _________________
7.
8.
9.
The Medical Letter on Drugs and Therapeutics, Vol.3, March 5,1971.
Drugs for Children, WHO 1987, p. 48.
Cyproheptadine: Risks and Unethical Marketing in Malaysia, Consumers
Association of'Penang Report, 1986. p. 16.
21
Apart from advertisements, sales promotion is done through
contests and competitions. This is well illustrated by the Indian
drugs and Pharmaceuticals Limited contest. It was a clear case of
targetting the medical profession, calling out, Doctors, get your free
Maruti Deluxe!”
MORE OF THE SAME
- Lysovit Syrup, a product of Pfizer is an example of irrational
combination. Aggressively promoted and widely sold, the
manufacturers claim that Lysovit "promotes growth, stimulates
appetite, increases gain in
weight, maintains optimum
LYSOVIT SYRUP
health .... and is the
delightfully
delicious
Vitamin Bl - 25 mg
growth
promoting
Vitamin B2-10 mg
vitamin-lysine tonic for
Vitamin B6 - 6 mg
growing children.
Vitamin Bl 2 - 50 mcg
Pantothenic Acid -15 mg
Inositol and pantothenic acid
(as Calcium Salt)
are
included in Lysovit but
Inositol - 30 mg
"there is^evidence of their
Niacinamide -108 mg
value.1 ’’The inclusion of
Lysine monohydro
inositol in multivitamin
chloride 200 mg
preparations have no
proved value and is unwar10.
22
British National Formulary No. 15,1988, p. 313.
~
~
~~
ranted"11 "Pantothenic acid has no accepted therapeutic used in
human medicine." Vitamin B12 is not effective by oral route
Vitamin B12 deficiency is treated by injection as it is more reli
able.1213
14
Encephabol
Encephabol Syrup, a product
of E. Merck is aggressively promoted
Pyritinol
and is very expensive. It is promoted
Hydrochloride 80.5 mg/5ml
as a cerebral activator, intended to
improve mental and psychic
retardation of growth in children. One 1988 promotional material
claims that encephabol is "the clinically proven drug that improves
performance in children with difficulties at school and that
encephabol is child patient's normal development".
"This is not true. The Normal brain
cells take the glucose and there is
no such mechanism by which the
uptake of glucose could be in
creased. Once the nerve cell is
damaged, there can be no regenera
tion. In cases of mental retarda
tion, parents get misguided in the
hope of getting the benefit by the
drug and correct management and
schooling is delayed}3
"This Vitamin B6 derivative was
used (from 1961 onwards) and then
largely abandoned as a psychos
timulant of doubtful efficacy."™
This drug was refused registration
in the Netherlands because of lack
of proven efficacy." "?
INCREMIN
According
to
the
industry's own code of
marketing, "Statements in
promotional communications
should be based upon
substantial scientific evidence or
other responsible medical
opinion." However, available
evidence suggests that the
promotional claims are not
capable of substantiation and are
misleading.
- Incremin syrup from
Lederle/Cynamid is an
irrational combination product
aggressively promoted by brand
name. Incremin is promoted as
a height gainer and as a Vitamin
tonic. It is irrational to combine
iron and vitamins. Vitamins
should not be added to iron
preparations except in case of iron
with folic acid: they add to cost
rather than therapeutic benefit.
L-Lysine Hydrochloride 300 mg
Vitamin B12-25 mcg
Vitamin B6 - 5 mg
Ferric Pyrophosphate - 250 mg
(Elemental Iron - 30 mg)
Sorbitol - 3.5 mg
Alcohol - 0.75%
11. American Medical Association Drug Evaluations, 6th edn, 1986, p. 850
12. Martindale - The Extra Pharmacopoeia 28th edn, 1982. p. 1645- 50.
13. International Consultation on Rational selection of drugs, VHAI1986, p. 164
14. Meyler's Side Effects of Drugs, 10th edn. 1984, p. 172.
23
"There can be neither theoretical nor clinical justification for the
inclusion of other therapeutically active ingredients in conjunction
with iron salts."10
As for Vitamin Bl 2 in the product, it is well known that it is not
effective by oral route. Vitamin B12 deficiency is treated by injection,
as it is more reliable.1
LEDERPLEX SYRUP
Syrup per 4 ml
Vitamin Bl - 2mg
Vitamin B2 - 2 mg
Vitamin B6 - 0.2 mg
Niacinamide -10 mg
Pantothenic Acid - 2 mg
Inositol -10 mg
Choline - 20 mg
- Lederplex Syrup/capsules,
a product of Lederle/Cynamid is
an irrational combination
aggressively promoted and widely
sold. A 1988 promotional material
claims that inositol and choline "in
Lederplex helps in restoring
normal liver function." Inositol,
choline and pantothenic acid are
included in Lederplex but "there is
no evidence of their value."1
"The inclusion of inositol and choline in multivitamin
preparations have no proved value and is unwarranted."
"Pantothenic acid has no accepted therapeutic uses in the
human medicine."15
19 As already point out, Vitamin Bl 2 is not effective
18
17
16
by oral route. Vitamin B12 deficiency is treated by injection as it is
more reliable.20
- Vi-Daylin Drops/Syrup, a
product of Abbott is an irrational
combination,
aggressively
promoted and widely sold. A1987
promotional material states "Take
cover under the Vi-Daylin
protection. Vi-Daylin provides the
right combination of essential
vitamins to build up strong and
healthy children!"
VI-DAYLIN DROPS:
per 0.6 ml
Vitamin A 5000 i.u.
Vitamin Bl 1.5 mg
Vitamin B21.2 mg
Vitamin B6 0.5 mg
Vitamin Bl 2 3 mcg
Nicotinamide 10 mg
Vitamin C 50 mg
Vitamin D 400 i.u.
15. British National Formulary No. 15,1988, p. 288.
16. Martindale - The Extra Pharmacopoeia, 28th edn. 1982, p. 1645.
17. British National Formulary, No. 15,1988, p. 314.
18. American Medical Association Drug Evaluations, 6th edn. 1986, p. 859.
19. Martindale - The Extra Pharmacopoeia, 28th edn. 1982, p. 1650.
20. Martindale - The Extra Pharmacopoeia, 28th edn. 1982, p. 1645.
24
Vi-Daylin range is advertised with claims like "On the right
track to healthy growth. During infancy Vi-Daylin Drops....delicious
citrus flavour. Gives infants a healthy start in life. Vi-Daylin
Syrup....ideal supplement for growing children....lemon candy
flavour makes growing great. Special formula for special needs.
Vi-Daylin-M helps children grow big and strong."
"The use of vitamins as general 'pick-me-ups' is of unproven
value and, in the case of preparations containing A or D, may actually
be harmful since patients will take more than the prescribed dose".
The only genuine indication for Vitamin C is the prevention and
treatment of scurvy. "Vitamin C is used to treat a number of
syndromes not associated with deficiency. However, efficacy in most
of the purported uses is unfounded, unproven or unsubstantiated".22
- Tetracycline with Vitamin C is a good example of an irrational
combination of an antibiotic with Vitamin C. Tetracycline being an
essential drug was found expensive because of the combination with
Vitamin C. Hence there was a ban of this combination. To
circumvent this, the drug industry Pfizer came up with the idea of
combining oxytetra-cycline with Vitamin C and B complex. This is
one way by which the industry beat the system.
Goodman and Gilman have very explicitly used the tonic
usage which is far beyond the required amounts. "The practising
physician is exposed to pressure from different types of extremists in
the area of vitaminology. One group, with representatives in medical
practice in a few pharmaceutical houses recommend large intakes of
vitamins both for prophylactic purposes and for the treatment of an
enormous variety of illness for which evidence of therapeutic efficacy
of the vitamins is lacking.
A study of the health practices and opinions reinforced the
concern of FDA in America that vast numbers of people hold some
erroneous concepts regarding the benefits of taking supplemental
vitamins and minerals.
The primary reasons for taking Vitamin supplements was the
erroneous belief that such supplements provide extra energy and
made one "feel better" and two thirds of those holding this belief did
21.
22.
23.
British National Formulary No. 15,1988, p. 313.
American Medical Association Drug Evaluations, 6th edn. 1986, p. 850.
Goodman and Gilman, Op.cit.
25
indeed claim to feel better. This is supported by the observations of
over-the-counter purchase of vitamins wi thout any concrete evidence
of deficiency symptoms.
It has been documented by authoritative sources that the use
of dietary supplements of vi tamins is medically advisable in a variety
of circumstances where vitamin deficiencies are likely to occur. Such
situations are likely to occur from inadequate intake, malabsorption,
increased tissue needs or inborn errors of metabolism.
Idisules Awareness Contest
What Has the Drug Industry Achieved?
The ritual of downing Vitamin pills and tonics is fast growing.
The promised results of revitality, rejuvenation, resistance to illness
and youthfulness appear very attractive to the consumer. A person
is asked to take a tonic when he experiences a tired feeling or fatigue.
It is normal to feel tired after a hard day's work. The relief is not in
any tonic but simply rest. Since the principal ingredient of most tonics
is alcohol, it is this alcohol which gives a feeling of elation and
suppresses the feeling of fatigue. What is forgotten is that it can be
habit forming and addictive.
It is true that Vitamin A and D are essential to growing children
and the requirement adequately met if the child is given the right diet
consisting of milk, green and yellow vegetables and egg. For those
who suffer from Vitamin A deficiency, the therapy outlined should
be taken far more seriously.
26
In adults an overdose of Vitamin D can do more harm than
good. Since it is essential for the utilization of calcium, excess of
Vitamin D can lead to retention of more calcium which in turn leads
to the formation of kidney stones. There are several such side effects.
The above findings from the promotional literature form part of the
study undertaken by the authors on behalf of the forum. It was
possible to take only a representative sample from the above and
analyse in-depth and they are illustrated. The outcome is indicative
of what is offered to the consumer by the entire range of products.
Further analysis of the current index of medical specialities
reveals that the unessential formulations fall under the following
different categories:
Kind of formulation
Iron preparations
Appetite stimulants
Minerals & Nutritive additives
Vitamins & Tonics
Electrolytes
Enzymes
Liver Tonics
No. of formulations
75
62
84
157
15
30
9______________ J
There are about 236 companies that have been listed in the
production of the above formulations.
27
fThe preliminary analysis also shows that the indications
for which they are recommended vary so widely
Indications
Iron preparations
Appetite stimulants
Minerals & Nutritional additives
Vitamins
Enzymes & Liver Tonics
Liver Tonics
38
37
64
81
23
9
A
AYURVEDIC HARD SELL
Another facet of the pharmaceutical industry is the
exploitation of the indigenous medicine in the garb of
herbal/natural/safe. This has acquired a new image with
multinational giants jumping into the fray. As a result it now
claims 15% of the overall market and the number of licensed
companies has doubled from 2000
to 5000 in just five years. The
Rs. 450 crore industry is
portends of an uncontrolled market growing at a rate of 30%
is frightening, considering that there annually, claiming 15% of
are no reliable standards laid down the overall pharmaceutical
nor effective machinery to check market.
India Today, March 15,1989.
quality and price control.
The principle of self reliance underlying traditional health
practices emerged as an alternative to the present day exploitative
system. Instead of bringing people closer to time- tested practices
and cures, the pharmaceutical companies responded and
succeeded in commercialising these systems. A study of the range
of ayurvedic products sold revealed that the emphasis was on
tonics and cosmetics. The claims of an ayurvedic tonic, whose
therapeutic value is impossible to evaluate, hold promises that are
high and mighty. The latest fad in this direction is the non-scientific
hybridization of the allopathic and ayurvedic principles of therapy.
29
This is analysed by Kamala Jaya
Rao.24 Few of the examples given by
her are -
Procter and Gamble
claim
that
ayurvedic
products give them a better
search to the market. 7% of
their products are ayurvedic..
India Today, March 15,1989.
Liv 52-
Achillea
Millefolium,
Capparis sponosa,
Casssia Occidentalis, Cichorium Intybus,
Terminalia Arjuna, Tamarix gallica, Solanum
niger, mandur bhasma
Bonnisari-
Achillea Millefolium, Capp sponosa, Cass
Occidentalis, Cich Intybus, Phyllanthus Embica,
Tamarix gallica, Term. Chebula, Tinospora
Cardifolia, Tribulus Ferristus, long pepper,
Cardamom.
The new look advertising, as
Zandu is spending 10% of
described by the manufacturers of
its Rs. 10 crore turnover on
Woodward's gripe water,speaks publicity.
volumes on the marketing of an India Today, March 15,1989.
'over the counter'product. What
can one infer? Yes, a classic
example of a simple home remedy turned into a money spinner
with more and more babies getting addicted to it.
The story of Woodward's
Warner Hindustan has
gripe water takes root in the last started selling its cough drops
century, 138 years ago. The TTK as ayurvedic. Duphor Interfran
pharma news letter carries a full has ensured the market with a
page write-up elaborating on the tension relieving medicine
safe, old ’’English” cure. The new called Ginsec.
advertising strikes a warm note of India Today, March 15,1989.
empathy: ’’Hindustan Thompson,
Bangalore, have come up with new look advertising for WGW to
make sure the new generation discovers WGW is every bit effective
as their grandmother insisted it was.
"The new TV spot for Woodward's gripe water narrates the
generation story with a difference.The brief but significant
inclusion of the lady doctor's testimony adds further credibility to
24 Kamala Jaya Rao - 'Allo-Ayurvedopathty - A Non-sdentfic Hybridisation',
Medico Friends Circle Bulletin (Jan-Feb, 1982)
30
Companies are also exploring
the untapped market.
Zandu exports over 1.5 crores
worth of ayurvedic medicines to
U.K. and S.E. Africa.
the brand's claims providing
just that extra push of
professional recommendation
that an 'over the
counter'
brand requires.
"Further help to recognise
woodward's specifically is
provided by the emphasis on
the 'snake and child' symbol
through a zoom-out and tight
close-up of the pack. The mere name Woodward's is repeated six
times in the space of 30 seconds to create recall.
Dabur is negotiating with
companies to set up ayurvedic
manufacturing units abroad.
India Today, March 15,19S9
"All this notwithstanding the real strength of the commercial
lies in the warm note of empathy it strikes in the viewer. In a
brief 30 seconds, the film captures a little scene in everyone's
home, from the quaintness of the elders to the charm of the smiling
baby that has been soothed with Woodward's Gripe Water."
FIRST FOR PROTECTION:
Liv.52
(drops/syrup/tabjets)
Liv.52 protects the liver
against the hepatotoxicity of:
— Paracetamol
— Oral Contraceptives
— Anti-tubercular Drugs
— Anti-cancer Therapy
— Antibiotics
— Alcohol
PAYING SO MUCH FOR SO LITTLE
Marketing of food products is taking big strides with the
burgeoning millions of the middle class.Catchy slogans are coined
to get the attention of the consumer to create new tastes.
For example"Heart beat of the family
"Horlicks” the great nourisher.
"Active-25 complete growth food.
The scientific formula for physical
and mental growth.
The health image of a beverage was reinforced by associating
it with the doctor. The role of the doctor in the marketing of
Horlicks is well known. While it helped in establishing the image,
as a health food, the focus has changed to market it as a family
beverage.
Horlicks or any other malted beverages have nothing unique
about them inspite of what some of their claims would suggest. To
see many of the claims in perspective it might help to substitute the
word 'food' for the brand name, says Charles Med war.
32
Thus, give your family food every day and watch them grow
in health and strength through all the years ahead. (Horlicks)
Give your children food every day, twice a day. It helps
provide them with the precious nourishment they need for their
growing bodies. (Bournvita)
Food taken regularly gives your family the nourishment that
builds up their resistance and keeps them full of health. (Horlicks)
The question that arises is "To whom is it of value"? From the
perspective of its cost and affordability it leads to a catch 22
situation. If the wealthiest can afford to buy it, it is they who least
require. The irony of the situation is that the undernourished who
probably would benifit from it can least afford it.This gives rise to
two questions.How do these foods and beverages compare with
any simple home made pre mix in terms of its cost and nutritive
value ? The answer is - in a home made pre mix the consumer is
paying largely for the raw material and paying perhaps up to 10%
of the cost of the market processed food. Where does the cost of the
marketed processed food go ? For example a beverage like Horlicks
consists of concentrated malted wheat flour. To this concentrate,
skim milk powder is added sometimes.
To
increase
the
fat
content "Heart beat of the family"
hydrogenated oils like vanaspathi are Horlicks
also added. The malting process is The Great Nourisher
essentially to break starch to dextrin by
enzymatic reactions. Taste is enhanced with sugar and other
flavourings. The common man is lured to buy the products at
unaffordable prices. Investigation into the break up of cost is
revealing.
33
NOW
ENRICHED WITH
EXTRA CALCIUM
COST BREAKUP
The raw materials like malted wheat flour, Milk solids, Fat
sugar and Vitamin amounts to 40 to 45% of the total cost. If the
processing is sophisticated, then the cost of the raw material comes
down further. Where does the balance cost go?
For every rupee spent on the purchase of such malted foods.
Only 40 ps goes towards rawmaterial, 12.5 ps towards financial
costs, 15 ps towards packaging , 25 ps towards utilities like power,
water and labour and another 5 ps as is distribution cost. This
leaves 3 ps for miscellaneous costs. The cost of advertising is over
and above these costs. To this is added an attractive profit.
SALES PROMOTION
Yet another method of promoting through hard selling is the
free distribution of samples and giveaways through door to door
sales. Horlicks, for example has been distributed and sold in
schools.
As a form of sales promotion,packaging is an important part
of marketing, ensuring the integrity of the product by giving it a
brand name, distinctiveness and consumer appeal. Very often the
styles of packaging have put the product beyond the reach of the
average consumer. One British executive managing a Bombay
based branch of a food product company, reported , "For our range
of food products, the expense of packaging alone adds on an
average between three to five rupees a kilogram."
34
ISSUES THREATENING A
RATIONAL DRUG POLICY
While unessential drugs proliferate the market, there are other
issues that deserve equal attention, in the formulation of a rational
drug policy. To list some of them -
(1)
Drugs banned by Government of India, but still
available in our country
One major reason why banned drugs are available in our
country is because of the legal loop holes. The drug
industry manages to get a stay order from the court on
the ban. Thus the banned drug floods the market. One
such example is Trinergic. Another drug, Amido pyrine a pain killer similar to Analgin in its toxicity, was
banned by the government of India but was available in
the market for quite some time after the ban order of 23rd
July 1983.
35
(2)
Drugs banned or restricted for use in other countries, but
still available in our country.
There are several such drugs in our market, the most
popular one is Analgin (Baralgan also contains Analgin).
(3)
Irrational cough syrups :
Medically speaking, there are two types of drugs for
treating cough : Expectorants act by bringing out the
phlegm present in the lungs. Suppressants act by
suppressing an irritating cough. Most of the
formulations are combination of both these and is
irrational. The only one benefiting from these are the
drug companies.
(4)
Instant remedies for cold:
There are several instant remedies for cold which are
sold in the market and advertised. All these claims are
hoax, because it is well known that cold is caused by
viruses and takes around a week for a person to recover
from an attack of cold.
(5)
Hazardous antidiarrheals sold in the market:
World Health Organisation recommends that no
antidiarrhoeal agent should be used in ordinary acute
watery diarrhea because most of the preparations are
either useless or even dangerous for children. It is a well
known fact that the cause of death during an attack of
diarrhea is dehydration and this has to be treated by
ORS. But several drug companies continue to
manufacture and promote antidiarrhoeal agents. Other
hazardous drugs that exist are like Butazones,
Clioquinols,
Anabolic
Steroids,
miscellaneous
ingredients in tonics that are unwarranted.
(6)
Promotional literatures of drug companies:
As outlined in this booklet, the drug information given
out by drug companies is extremely unreliable. So there
needs to be a study done looking at it from a scientific
rational angle.
36
IS IT TRUE?
(1)
Are you not producing quacks by making available so .
much information ?
To be healthy is a persons right and so a person has a
right over his/her body. He/She should be fully aware
of what is being done to his/her body so to that extent
he/she has a right to know about drugs that are
commonly used.
And again it also helps the doctor, in explaining to
him/her about the disease process and drugs if he/she
has the same knowledge.regarding the same.
(2)
Are you not putting conflicts in the mind of people ?
No! We are only trying to give scientific and necessary
information to common man, so that medical science
gets demystified.
(3)
Is it not the doctors job to know all this and is this not
taught in medical colleges ?
After passing medical examination, doctors are
inundated with information given by drug companies
with little lime or inclination for reliable sources of
scientific information. The promotional material of a
drug company is aimed at popularising the drug while it
does not give the complete and correct scientific
information. Many a time doctors get information that is
quoted out of context. Gifts from drug companies help
them to reinforce the product and brand name in the
prescription.
(4)
The doctor says, "patients are asking me to prescribe
tonics etc for them. What shall, I do ?"
And when a doctor succumbs a scientific thought is lost.
Doctors need to spend more time with patients
37
educating them and also voluntary organisation and
government should come forward to educate people on
these issues.
(5)
The drug industry employs so many people. What will
happen to these employees ?
The same drug industry which is involved in producing
unessential and hazardous drugs, should start
producing drugs essential for people.
(6)
Why doesn't the government ban tonics ?
As mentioned in this booklet, even drugs banned in our
country are available in the market, so banning alone
will not help, but should be coupled with consumer
awareness.
38
(7)
In India there is so much malnutrition, so don't we need
vitamin supplements ?
For malnutrition what people need is food and not
vitamins. Moreover such costly and unessential tonics
preparations are out of reach of the poor and do not
provide the required nourishment.
(8)
If allopathic tonics are useless then what about
ayurvedic and other non-allopathic tonics ?
The word tonic has relevance in other systems. It is
important to understand the wholistic approach of a
system like ayurveda and commercialisation of any
system does no good to people. According to ancient
texts tonics like Chyawanprash when prepared with care
produce near miraculous cures. But this cannot be said
of commercially prepared Chyawanaprash available in
the market.
39
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