People with ailments are usually obliged to buy whatever medicines are prescribed for them by the physicians. But many people do not know that in some medicines the profit margin is as high as 7079 per cent, or raw materials worth $ 7.0 are sold at $ 275 in some countries, or vitamins available in the market contains substances worth only a few paisa, or the sleeping pill which is sold at 50 paisa costs only 5 (five) paisa to manufacture. These are merely stray examples of what goes on in the mighty medicine empire - dominated by large multinational companies, their local subsidiaries and domestic conglomerates. But the ordinary citizens certainly have the right to know why and what medicines are prescribed for their ailments.
Medicine is not an ordinary commodity. All medicines affect human health and lives. It is not sold like other products in a free market. A patient is not supposed to buy medicines of his choice on his own. He buys medicines according to the prescription of his physician. Here the preference of the consumer is not relevant.
The National Academy of Science and the National Research Council of the USA carried out a survey on 2000 medicines in 1971 and found that there was no scientific proof of the effectiveness of 60 per cent medicines. As a follow-up, many medicines were withdrawn from the market as per government directives. But why were so many useless or unnecessary medicines still in vogue in the market? The book, The politics of drugs: the British and Canadian pharmaceutical industries had an answer. It said: "Although an old method, bribery is still very effective. The lobbies of the American pharmaceutical companies buy the votes of American Congressmen as easily as we buy Aspirin".
In the book 'Jey Sangramer Shesh Nei: Oushadh Nitir Andarmahal' (The Unending Struggle: Inside the Drug Policy, 1998), the author Majnunul Haque cited some interesting examples of how the pharmaceutical companies influenced the physicians' prescriptions. He disclosed that a doctor in Faridpur was given a TV set by a company, another a refrigerator. Another lady doctor who was gifted a gold chain said, "When they help me in such a big way, isn't it my responsibility to help them"? Such is the psychology of many physicians. Even sponsoring foreign tours of doctors, especially of specialists, by pharmaceutical companies has now become quite common in Bangladesh.
According to an estimate, 20 per cent of the revenues earned from the sale of medicines are spent on publicity campaigns by the pharmaceutical companies. A researcher in Switzerland found that the more a medicine is publicised, the more frequently it is prescribed -- sometimes even unnecessarily or excessively. While carrying out publicity campaigns, the pharmaceutical companies take recourse to various devious ploys. For example, the harmful effects of medicines, which are mentioned in developed countries, are seldom stated in the same manner in the developing ones. Medicines are also sold at different prices in different countries. For example, Diarrhoea control drug Mexaform was once sold at 4 times its Swiss price in Mexico, 6 times in Indonesia, and 13 times in Niger. There is no justifiable reason for this variation except for dishonesty and greed for windfall profit.
Although the multinational pharmaceutical companies show less profit to avoid paying higher income taxes, in reality their profit is often sky-high. This profit is earned through various clever ploys like transfer pricing, product patent and brand names. These companies buy raw materials of medicines from their parent companies or their branches where the pricing is not competitive. This price is often shown to be very high. In this way, local resources and money are transferred outside the country. Moreover, by showing inflated raw material price, less tax is paid.
The drug companies also earn undue profit by misusing patents or copyrights. These ensure their monopoly for a long period. Another technique used to elicit undue profit is the use of brand names, which are implanted in the minds of the physicians by the medical representatives. And the patients are forced to buy whichever brands of medicine are prescribed by the doctors at whatever price. This prevents the patients from comparing the prices of similar generic medicines produced by different companies. It may be pointed out here that the generic names of medicines are derived from their actual chemical composition.
FINDINGS OF THREE COMMITTEES: Many unknown aspects about the medicine empire came to public view through the findings of three committees between the 1950s and 1970s, namely the 'Sainsbury Committee' in the UK (1965), the 'Antitrust and monopoly sub-committee' headed by Senator Estes Kefauver in the USA (1959), and the 'Jaisuklal Hathi Committee' in India (1974). The Sainsbury Committee found in 1965 that 35 per cent of the medicines circulated in the UK market were useless, unnecessary or harmful. In the USA, Senator Kefauver recommended reduction of patent period from 17 to 3 years in 1962, but ultimately that could not be implemented. It was found in the USA in 1979 that one out of eight prescriptions contained unnecessary drugs. Another survey, in 1992, found that more than one billion dollars were spent by the public each year on useless and harmful drugs. The Hathi Committee in India recommended in the 1970s the use of 116 generic medicines composed of single ingredients instead of thousands of unnecessary mixtures. But its recommendations could not be implemented as the multinational companies obtained an injunction from the High Court in 1981. Similar attempts in Pakistan, Sri Lanka and the Philippines were thwarted by the multinationals through legal and other means.
It is in this backdrop that the need for some sort of state control on the quality and prices of medicines arise, as an uncontrolled medicine regime tends to have terrible consequences for society. The arguments behind attempts to introduce Drug Policies in different countries of the world included combating price fixation on false pretexts, curbing varying prices for the same medicine at different places, tackling the claims of excessive cost for research and lesser profit margin (for tax evasion), and discouraging the sale of unnecessary or harmful drugs. But whenever attempts were made in the past to introduce a drug policy for removing these anomalies, owners of drug companies and many medical professionals opposed them. Their resistance, lobbying and influence were so strong that many governments had to abandon the idea at different junctures.
A BIG BREAKTHROUGH: It was a big breakthrough when Bangladesh adopted a Drug Policy in 1982 in the form of a Drug Control Ordinance. It was the outcome of painstaking works by a committee of dedicated experts headed by Professor Dr. Nurul Islam and comprising such luminaries as Dr. Zafrullah Chowdhury. The committee expressed the view that medicines made from a single ingredient are the best; the alternatives made of mixtures not only increased the cost, their effectiveness also decreased. The committee examined 4,170 types of medicines available in the market and found that they were composed of 150 ingredients. Of them, 1,707 were found to be unnecessary, many were found harmful and therefore banned earlier in many developed countries.
The committee fixed 16 criteria based on scientific quality and socio-economic perspective on the basis of which medicines were to be evaluated. The foreign companies were asked not to produce antacids and vitamins anymore so that their expertise and financial capacity could concentrate on producing essential and life-saving drugs. On the other hand, this facilitated the entry of local companies (with lesser capital and experience) into the lucrative vitamin and antacid market.
Opposition to the Drug Policy has continued since its inception and some of its clauses were revised (e.g., the number of essential drugs were raised from 45 to 117 and price control on the rest withdrawn in 1994) due to pressure from pharmaceutical companies and other vested professional groups like Bangladesh Medical Association. But the policy benefited local pharmaceutical industry both in terms of share in total output and sales turnover. As a result, their share of essential drugs which was only 30 per cent of total production in 1981, rose to 80 per cent in 1991. Other positive outcomes included reduction in the price of medicine, flourishing of local pharmaceutical companies, declining import dependence and so on.
The Drug Policy has to be carried forward through an evolutionary process. For that, amendment or revision is no doubt required, but cancelling or curtailing it for the sake of a free market would be counter-productive, and would certainly go against public interest. In order to safeguard it, common people have to remain vigilant about the local and foreign vested quarters and their self-serving designs. Another name for this vigilance is 'struggle', a struggle that must be won for the sake of healthy living of humankind.
Dr. Helal Uddin Ahmed is a retired Additional Secretary and former Editor of 'Bangladesh Quarterly'. firstname.lastname@example.org