October 3, 2002

     Can you name a place or a situation where a toe fungus and a great steak dinner can go together?

     Highly unlikely, but not at a medical convention or a scientific meeting, as it is more commonly referred to. A lecture on "Cutaneous Fungal Infections" with an accompanying steak dinner? Sure. A speaker talking about "101 Organisms You can Find in a Bowl of Sputum" while the audience is eating spaghetti and meatballs? Why not?

     You see, at a scientific meeting, you are not only there to attend a 'meeting' or listen to a 'lecture'. You are there to eat too, you sometimes refer to it as scientific 'eating'. That's just the norm, the common practice. If you get invited to a one-day scientific meeting or a one-week medical convention, you are not expected to bring a lunchbox, or pay for your own hotel or plane ticket. In fact, you are not expected to pay for anything. And if you don't know who pays for all that, your brain is in serious trouble, you probably don't know your own name, either.

     I will not run the risk of taking my colleagues own opinion with me so I'll play it safe and talk about my own experiences.

     I was well into my first year of medical residency when one of my consultants asked if I want to join him at a convention sponsored by The Philippine Heart Association (PHA) in Manila. I answered yes without batting an eyelash. That's as fast as Jerry G. can say yes to a free lunch.

"In 2000, Merck [& Co.] spent $161 million on advertising for Vioxx. That is more than PepsiCo spent advertising Pepsi ($125 million), and more than Anheuser-Busch spent advertising Budweiser ($146 million)."

     I was excited for two main reasons. One, the last time I've been to Manila was quite some time ago, Bon Jovi's Bed of Roses was on top of the music chart, and people were still dancing the Macarena. Two, I couldn't believe the consultant actually said something nice to me. 'Are you sure you finished medical school?','What book did you read that from?' were some of the questions he asked me on a daily basis before that day.

     I actually had a third reason to be excited. 'I will find you a sponsor,' said the consultant. Wow, does that mean I won't have to stay in my cousin's place?

     The following week, a pharmaceutical company representative ('drug-rep' for short) walked up to me and introduced himself as 'the sponsor'. He gave me the plane ticket and the reservation for a three-day stay at Edsa Plaza Hotel in Mandaluyong. Before I could say thank you, he gave me a business card of some car-rental company complete with a driver with instructions that I could call anytime if I need a ride. He also gave the name and number of his Manila counterpart who he said, 'will really take care of you'. Geez, what pampering, I felt like a politician's wife.

     Fast-forward to the plush Edsa Plaza Hotel where the consultant and I were billeted. I would not have thought the hotel was that plush if I hadn't seen so many 'famous' people in the lobby. The most famous I actually met face-to-face (in the elevator, at least) was pop singer Phil Collins who happened to have a concert in Manila that week. Yes, that Phil Collins, no kidding. I was so shocked myself, all I managed to say was 'Hi there.' That should be enough but, hey, I could have asked him 'hey, Phil, what the hell does Sussudio mean anyway?' From the upper floors to the lobby, all I did was stare from floor to wall while his other hit 'Against All Odds' kept playing on my mind. That song aptly represents my college love-life.

     To make this long story short (it's not too late, is it?), the consultant and I stayed in Manila for four days and maximized every 'hospitable offering' from the drug company that came our way. I am too embarrassed to mention most of them here. What I am not embarrassed about is, that trip was clearly a junket for me. I have not even listened to a single lecture, even if I tried I wouldn't have understood any of it.

     What I have learned from that experience is that drug companies will do whatever it takes to entice physicians to prescribe their products. I was just a mere resident from an unaccredited training program, first year at that, near the bottom of the totem pole of physicians, and I was treated 'very well', at least to my standards. How about the hundreds or thousands more, consultants and specialists, that the drug company sponsored. The budget for them may be ten times more. Of course, we did not really ask for it (in my case, my consultant did), but it doesn't take a genius to figure out where the drug company will get the money back.

     Probably not even a fraction of a cent was added to the price of Captopril because of my trip. It may not have mattered at all. It may matter, however, if you multiply that with a few thousands. You are now perhaps getting my drift here. Am I picking on drug companies sponsorship of physicians as the only cause of rising drug prices? Certainly not. Could it be one of the causes? Hmmm...let me think about that.

     In late 1999, the House of Representatives started an investigation of the overpricing of medicines by drug companies which, according to them, has placed the life saving-commodity beyond the reach of many Filipinos. That's eleven years after the implementation of the Generics Law, the main purpose of which was to lower the prices of medicine. Wait a minute. Has the law failed? Or is this law the right law to lower prices of medicine?

     Then Secretary of Health Alberto Romualdez vowed to reduce prices of medicine by 30-60 percent. Romualdez said, as quoted by the Philippine Daily Inquirer in its November 9, 1999 issue, the price reduction would be made possible through a series of orders that would include stricter compliance with the Generics Law, limiting the use of branded drugs, and requiring pharmaceutical companies to manufacture the generic equivalents of their branded drugs. Am I missing something here? Weren't these provisions of the original Generics Law? Eleven years after its implementation and we are still enforcing it? Or, aren't we barking up the wrong tree?

     On the same Inquirer issue, House Majority Leader Manuel ''Mar'' Roxas II filed a resolution calling for an investigation of the alleged overpricing of medicine by as much as 500 to 1,000 percent. "There is a multi-faceted issue to drug over-pricing and this should be tackled immediately because the poor has long been deprived of low costs of medicine and health services for far too long," the congressman said. It may have come from a congressman but that is clearly a sensible statement.

     Roxas also raised the practice of overpricing drugs when the House committee on health met to discuss House Bill No. 76. The bill seeks tax relief on the importation of medicine, equipment and other raw materials used for the manufacture of medicines. I am not sure but I think this bill is already in effect. It has definitely lowered the cost of drugs considering generic drugs from such countries as India are way much cheaper than the locally manufatured. If that's not killing the local drug industry, I don't know what will. But are these "cheap, tax-free" drugs popularly prescribed? Is this another case of barking up the wrong tree?

     Roxas said that drug prices were overpriced because over P1 billion or 25 percent of the costs incurred by the pharmaceutical industry had been earmarked for marketing costs. I don't know about you but this is one of a few times that I have to agree with a politician.

     Independent analysts had suggested that "the high cost of medicines in the local market is a function of the pharmaceutical industry's dependence on marketing, advertising and promotions as a tool to ensure steady sales. Marketing costs include the representation expenses to entice physicians to prescribe their branded drugs to even poor patients."

     Roxas also said the "huge budget set aside by medical companies for the purpose of luring physicians into prescribing their drugs defeats the objectives and mission of the Generic Drugs Act." He noted that only "one out of 10 consumers buy generic drugs because doctors and pharmaceutical companies continue to recommend branded products." We can always question these statements but I won't hesitate to say that these are facts that only a few of us are willing to admit.

     This translates to a mere 40-percent compliance of the Generic Drugs Law, 11 years after its implementation. Compliance with the law hit a high of 80 percent in 1988. Sales of generic drugs represented only 8 percent of total pharmaceutical sales in 1996. Can we start barking up the right tree now?

     Of course, there are other factors that have led to the high costs of medicines like graft and corruption in government purchases and collusion and price-fixing by pharmaceutical companies with retail outlets. Also, drug firms were also passing on to consumers their tax burden. I am not denying that but let's deal with the obvious ones.

     When the Generic Drugs Law was a pending bill in Congress, the Philippine Medical Association (PMA) vehemently protested against it. If I remember it right, the main contention was the law isn't the solution to the rising drug prices. On the contrary, it will only spur the appearance of counterfeit drugs like a capsule with baby powder on it instead of Amoxycillin. Drug prices continued to rise and a lot of counterfeit medicine have been seized since. In retrospect, PMA was right, and that clearly is a double-whammy for the Generic Drugs Law. I am not sure though if PMA at that time offered an alternative solution to the problem or the fear of drug companies stopping sponsorships of medical conventions was even a concern (since physicians are required to prescribe generics, anyway). You know, how can we go on with continuing medical education if nobody's going to order the pizza?

     Even if the Generic Drugs Law or its equivalent was successfully implemented in the United States and other countries, rising drug prices is still a concern. I was looking around for similar views on this issue when I stumbled upon a story in the World Street Journal that came out June of this year. It tells a story of a fourth year medical student at Brown Medical School who carries her revolt against the world's drug industry in a yellow lunchbox.

     Funny. I mentioned at the top of this column that you will not ever see a doctor bringing a lunchbox to a scientific meeting but this lady actually did and probably is still doing it. She used to join her fellow students at Brown Medical School in scarfing up the free lunches, pens, notepads and other gifts dished out by pharmaceutical makers at Providence, Rhode Island, teaching hospitals. Then, two years ago, she decided to stop. She started bringing her own sandwiches to lectures where drug companies provided lunch. She went through her lab coats and threw out all the pens and notepads emblazoned with drug-company logos. She even tossed the fun freebie from a Viagra sales rep - a Viagra calculator that stood up on a base when the "on" button was pressed.

     The story mentions that this lunchbox-toting student is part of a growing movement among students and some teachers trying to curtail the drug industry's efforts to woo young doctors as future customers. "We need to find some way to reclaim the moral high ground," the Journal quoted her as saying (whatever that means).

     A national campaign was actually launched calling on students to sign pledges swearing off all drug-industry gifts. Students were also urged to ditch their drug-company pens, or at least put tape over company logos. And the medical student plans to push officials at Brown University's medical school to limit interaction between drug-company salespeople and students.

     By golly, these students are serious. At a recent luncheon at Washington University in St. Louis, continues the Journal article, leaders of the local chapter of the American Medical Student Association handed out cans of soft drinks affixed with labels taking digs at drug-industry marketing. "In 2000, Merck [& Co.] spent $161 million on advertising for Vioxx," one label read. "That is more than PepsiCo spent advertising Pepsi ($125 million), and more than Anheuser-Busch spent advertising Budweiser ($146 million)."

     Still according to this Journal article, research has shown that industry largely influences doctors to the point that some improperly prescribe - or overprescribe - certain drugs. It also may affect how much consumers pay. A study in the Journal of the American Medical Association in January 2000 said doctors who were more inclined to interact with drug reps were less likely to prescribe cheaper generic drugs.

     The industry disputes many of these findings (of course, duh), arguing that its salespeople provide physicians with useful product information, and that doctors are too smart to let free tickets affect prescription decisions.

     But there is little dispute that drug makers spend big money - more than $16 billion in 2001, according to one estimate - cultivating physicians and medical students. Critics say these ever-rising costs contribute to rising drug prices.

     This is so obvious that U.S. lawmakers couldn't help but notice. Remember the toe fungus and steak dinner I mentioned at the top of this article? I did not make it up. Democrat Rep. Pete Stark of California released these invitations: "Stop by for some literature and a free bottle of wine, courtesy of Organon’s ‘Wine and Dash.’ You and a guest get a steak dinner while listening to a Novartis lecture on toe fungus. Go to see the Tampa Bay Devil Rays play courtesy of Pfizer. Play golf at the Westin Innisbrook Resort courtesy of Celexa." Stark is the author of legislation (HR 4089), "The Save Money for Prescription Drug Research Act of 2000" would deny tax deductions to drug companies for certain gifts and benefits provided to physicians (other than product samples) and instead encourage drug companies to use those funds for pharmaceutical research. "No wonder Americans are charged the highest prices in the world for drugs – our drugs companies spend billions on ads and gifts to doctors that instead should be spent on research and lowering the cost of drugs," added Stark.

     I'll choose the steak dinner. I don't play golf and baseball's Tampa Devil Rays are always in last place in their division. Okay, who cares. I already met Phil Collins.

     I talked to Dr. Dan Garganera (1994) recently and asked him about his experiences at Loyola University Medical Center in Chicago where he did his residency. He said he's been to many out-of-state conferences with first-class accommodations courtesy of drug companies. This year, however, this will stop, according to Dan. A newly-passed legislation (I am not sure if this is the one authored by Rep. Stark and just recently passed), will prevent or limit drug companies for sponsoring such trips.

     We will see if this will have an effect on drug prices. We will see if somebody's finally barking up the right tree.

     Meanwhile, let's go back to our own. Is the Philippine Generic Drugs Law a failure?

     How many more years until we decide to replace the question mark with an exclamation point?

     This week's FINAL WORD comes from Dr. Cynthia Cabangal-Ng:

     "...I thought all the while that you are still that silent little guy trying his best to listen to me talk."

     Don't believe the hype, Doctora. Nothing has changed.

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     The author's e-mail address is at drgarcia@wvsumedaa.com

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