Free Lunches Come at a Price

In the end, “it’s the patient who pays”
Critics say doctors should be forced to disclose goodies they receive from drug company reps

Alex Roslin
Saturday, September 12, 2009
The Montreal Gazette

Adam Hofmann is used to getting teased about his lunch. It’s not because his mom gave him something uncool to eat. It’s because he paid for it.
Hofmann is a doctor and fifth-year medical resident at McGill University. Lunchtime is often when residents attend talks on medical topics organized by various disciplines in the three teaching hospitals where Hofmann works—the Montreal General, Royal Victoria Hospital and the Jewish General.
Sales reps from pharmaceutical and medical-equipment companies provide the food and sponsor the speaker at many of the talks, he said.
The sessions, known as “rounds” among doctors, occur two to four times a month within any given hospital discipline like cardiology or internal medicine, Hofmann said.
Drug reps also frequently provide food and sponsor speakers at monthly “grand rounds”—talks to entire hospital departments like pediatrics or family medicine—and “journal clubs,” meetings at restaurants or doctors’ homes at which medical papers are discussed, he said.
While his coworkers partake in sushi takeout or a catered spread, Hofmann sticks to cafeteria fare and braces for the funny looks. He is virtually always the only attendee to pay for his meal. “I have occasionally gotten sarcastic remarks. I’ve been called a ‘pinko’ and a ‘communist’,” he said with a laugh.
With 10 to 20 rounds taking place each day in an academic hospital, Hofmann said staff are able to eat lunch for free all week if they want to, and some do. “A few residents have made it a game to never pay for lunch if at all possible, even going to the length of seeking out lectures they would not otherwise be interested in,” he said.
He estimated that the average resident in academic hospitals eats for free two or three times a week.
For Hofmann, brown-bagging it is a small price to pay to avoid the cozy interactions that many medical professionals have with pharmaceutical sales reps.
Questions about drug marketing practices are coming under growing scrutiny in Canada and the U.S. In August, McGill professor Barbara Sherwin was embroiled in questions about a journal article that was ghostwritten for her by a company working on behalf of a pharmaceutical firm.
Last week, the drug giant Pfizer Inc. agreed to pay $2.3 billion U.S. to settle criminal and civil allegations that it had illegally marketed several drugs for unapproved uses and rewarded doctors with kickbacks. It was the largest criminal fine in history and was Pfizer’s fourth settlement for illegal marketing in the U.S. since 2002.
Little data exists on the extent of the marketing activities in Quebec. One of the few Canadian studies found, in 2006, that 42 per cent of general practitioners in B.C. got visits from drug sales reps several times a week. Two-thirds saw them at least once a month.
The visits are part of vast, multi-billion-dollar marketing campaigns that include food brought to doctors’ offices, restaurant meals, trips, high-paying gigs as consultants and speakers, drug samples, research grants and continuing-education talks that doctors attend to maintain their licences.
Critics say the marketing is poorly regulated and that a growing pile of studies shows the perks sway doctors to prescribe costlier drugs that aren’t necessarily the best ones for their patients—a major reason for soaring health-care costs.
“The gross majority of interactions that physicians have with pharmaceutical companies are unnecessary and problematic,” said Hofmann.
Pushing pills involves fantastic amounts of money. In a study in 2008 in the journal Public Library of Science Medicine, two Canadian academics, Joel Lexchin and Marc-André Gagnon, calculated that pharmaceutical companies spent $57.5 billion on marketing in the U.S. in 2004. That was nearly double the $32 billion spent on researching and developing drugs.
The marketing budget included $20.4 billion for an army of 100,000 “detailers,” as the sales reps are known in the business. That worked out to about one detailer for every nine doctors; their numbers had swelled by nearly three times since 1995.
In Canada, there were 5,190 detailers in 2002, or one for each 11.4 doctors, according to a 2006 study by the University of Victoria’s Drug Policy Futures research group.
All those detailers and marketing bucks have big impacts on medical decisions of doctors, according to one of the most comprehensive scientific reviews of the question, done by Dr. Ashley Wazana, now a psychiatrist at the Jewish General.
In a paper in the Journal of the American Medical Association in 2000, he reported that doctors who accepted funding for a trip to a company-sponsored conference prescribed that company’s drugs 80- to 190-percent more often than those who hadn’t.

Those who “occasionally” ate pharma-sponsored meals were 2.7 times more likely to request that the sponsor’s drug be added to a hospital formulary (a hospital-approved list of drugs). Doctors who “often” ate the meals were 14 times more likely to do so.
The review also noted that hearing a drug salesman at a talk led doctors to recommend “inappropriate treatment” more often than other doctors, including treatment that cost more and was more invasive.
Wazana also found that just one in five doctors agreed that pharma reps “fairly portray their product.” Three-quarters of residents said the reps “may use unethical practice.”
Despite this, most doctors have some interaction with detailers. Four in five residents attended industry-paid meals, with the average resident eating on the corporate dime 14 to 15 times a year, Wazana found. Interns did so 31 times a year.
Among doctors, 85 to 87 per cent said they had some interaction with detailers, with an average of three to four encounters a month. Eighty-six per cent accepted free drug samples, and half got research grants.
The interactions start right in med school. A survey of 826 U.S. medical students published in 2005 found that 97 per cent had received some form of gift from pharma reps. Students got gifts or attended a sponsored activity an average of once a week, and they ranged from lunch to parties, trips and candy. More than two-thirds said the gifts would never influence their prescribing practices.
In fact, many doctors rely on detailers more than any other source for information about new drugs. U.K. doctors said drug reps were their most important source of initial information in a third of the cases when they prescribed new medicines, with pharmaceutical marketing accounting for another 15 per cent, according to a 2003 study in the journal Family Practice.
That study also reviewed 616 prescriptions the doctors had written. The doctors cited pharma reps more often than any other factor as influencing their prescription choice. The reps were cited 39 per cent of the time, far more than concern about the drug’s side effects (17 per cent) or prescribing guidelines developed by the medical community (15 per cent).
The marketing has paid off in spades for the pharmaceutical industry, according to a 2002 study by Yale University marketing professor Dick Wittink. He found that each dollar spent lobbying doctors through sales reps and pharma-sponsored events returned nearly $12 in increased prescriptions for brand-name drugs.
At the Quebec Medical Association, which represents 9,000 doctors and medical students, an official said the research is news to him. “We are not aware of that. We haven’t studied this question,” said Robert Nadon, the association’s director of professional affairs.
“We think doctors are professionals and that they will respect their ethics code.”
Russell Williams, president of Rx&D, the Canadian lobby group for brand-name drug companies, said member companies follow an ethics code, which says product information given to medical professional must be “accurate and fair” and that gifts to doctors can’t be “excessive” and must be limited to “modest meals and/or refreshments.”
The code adds, “Hospitality should not be utilized as the primary access to meet with health care professionals, but as an opportunity to expand the business discussions.”
“I believe our industry is dealing with this issue in an upfront way,” said Williams. “We’re not selling shoes here. These are complex molecules. We need to have dialogue with doctors.
“There is a significant engagement from our side to make sure that the relationship is of the highest ethical standards. It is working quite well.”
Officials at the McGill University Health Centre, the Jewish General and the Centre hospitalier de l’Université de Montréal couldn’t be reached for comment.
The body that represents Quebec hospitals and CLSCs has no policy on staff interactions with pharma reps, said Eric Côté, spokesman for the Association québécoise d’établissements de santé et de services sociaux. “Technically, doctors are autonomous workers.”
Côté referred calls to the Quebec College of Physicians. The college said it expects doctors to abide by its ethics code, which says continuing education classes must be “balanced” and that doctors should avoid conflicts of interest. Doctors can’t accept commissions or benefits for having prescribed a drug, but they can accept “customary presents and gifts of modest value.”
But critics say the rules are nebulous. “It’s so vague as to be completely useless,” Hofmann said.
“Also, there are generally minimal and infrequent repercussions associated with these kinds of ethics code violations.”
“Drug companies would not be detailing physicians if they didn’t have a huge return on investment. They’re in the business of making money,” said Jeff Connell, spokesman for the Canadian Generic Pharmaceutical Association.
Connell said his association’s members lose business and patients pay more when detailers steer doctors to more expensive brand-name drugs that aren’t necessarily more effective than similar generic versions. When a drug’s patent is about to expire, he said, brand-name pharmaceutical companies often make minor changes so they can patent the medicine anew and then get doctors onside with aggressive marketing campaigns.
Indeed, of 177 new drugs approved in Canada since 2001, federal regulators deemed that 156 (or 88 per cent) fell in a category of drugs that show “moderate, little or no therapeutic advantage over comparable medicines.” Just 19 of the drugs were considered “a breakthrough or substantial improvement,” according to data from the federal Patented Medicine Prices Review Board.
Rx&D’s Williams disputed the board’s data, calling it “inadequate in reflecting serious, incremental innovation. It’s not telling the real story.”
When Shahram Ahari was hired as a detailer in New York City by a major U.S. pharmaceutical firm, he was surprised when he met his co-workers. At the company’s intensive, six-week boot camp for detailers, he said he met hundreds of fellow college grads, mostly in their mid-20s, perhaps two-thirds of them women—the vast majority beautiful. He was the only one in his class of 22 with a science degree.
“They were 200 or 300 of the most attractive people I had ever seen. The physical appeal was only part of it. They were vivacious, well-coiffured, well-dressed, engaging people,” he said.
The training was part CIA, part Freud. Ahari learned to quickly scan a doctor’s office and spot anything that could be used to strike up a personal conversation and, with luck, friendship—golf paraphernalia, photos of trips or kids, religious items. The information would later be entered into the company’s file on the doctor and analyzed for future approaches.
“It was analogous to training in spy agencies. You instantly suss up the person’s personality and look for points of entry. You capitalize on sexual appeal. My more attractive colleagues would say, ‘I’m going to wear my short skirt today,’ or ‘I’m going to wear my low-cleavage top. He (the doctor) seems to get a kick out of that,’” he said.
His in with many doctors was their belly. “Food is a pretty powerful catalyst for sales. I sometimes saw myself as a glorified caterer,” he said.
Food would often have a greater impact than his best arguments about a drug’s merits. “I would argue with doctors until I was blue in the face (about a drug). Then I’d take them out to dinner and see their (prescription) numbers rise,” he said.
Ahari often provided food at hospital “rounds,” and he was also careful not to neglect the staff at doctors’ offices; they could be useful for scheduling appointments with doctors and putting in a good word about his company’s drugs.
“There’s almost a sub-art to figuring out which food people will like. How successful and delicious your lunch is has a sway in terms of how quickly you can get meetings (with the doctor),” he said.
He rewarded high prescribers with an invitation to join the company’s “speaker’s bureau.” That meant lucrative gigs addressing other doctors at company-sponsored lunch and dinner meetings and medical symposiums. Speakers typically earned $100 to $500 for a lunch or dinner presentation and up to $10,000 for a major conference talk.
“We’re constantly monitoring our return on investment. We’re not a charity,” Ahari said. “There’s no such thing as a free lunch. It’s the patient who pays.”
The revelations about drug marketing practices have pushed a few U.S. states to ban gifts to doctors, limit their value or require them to be disclosed publicly.
In Canada, there has been less scrutiny and less action. Some provinces, including Ontario and B.C., have sent out small numbers of so-called “academic detailers” in an effort to counter the pharma message and provide independent drug information to doctors.
But critics say a handful of academic detailers can’t possibly counter the huge numbers of pharma reps and that doctors have shown they can’t police themselves.
Ahari and Hofmann both said doctors should be forced to publicly disclose any benefits they receive. Another measure, said Hofmann, would be for revenue authorities to require doctors to include free drug samples and meals as income and to tax it.
Ahari said he eventually quit his job as a detailer because of his rising ethical concerns. “Not only are you fooling your (doctor) clients, you’re fooling yourself that you’re doing something good,” he said. “I felt I had become such a calculating social manipulator I would be thinking like a chess game in every social encounter with my girlfriend and family. It was horribly disconcerting.”
Ahari has since spoken before Congress, at medical schools and to the American Medical Association about detailing and conflict of interest. He is now attending medical school himself at the University of California at Davis.
Back at McGill, Hofmann hopes his cafeteria lunches will get a colleague or two to question the price of the food they’re enjoying.
“It’s an obvious stance that physicians should take. Getting gifts from an industry that seeks to manipulate your prescribing practices and may adversely affect your patients is unethical.”

Alex Roslin is vice-president of the Canadian Centre for Investigative Reporting.

Statistics Hog-Tie Pig Farming to H1N1 Cases

By Alex Roslin
August 27, 2009
The Georgia Straight
[Click here for the story at the Straight website]

As hospitals brace for the coming flu season and a possible new surge of H1N1 cases, international data on the flu pandemic shows it has hit Canada worse than almost any other country.
And a close look at the data suggests that a key factor may be something that health authorities have largely overlooked: hog farming.
Canada had the sixth-highest number of H1N1 cases per capita and the fifth-highest per capita rate of H1N1 deaths of all 134 countries and dependencies that had reported flu cases to the World Health Organization as of July 6. (That’s the last date for reliable international comparisons, because the WHO advised countries in early July to stop reporting data on individual H1N1 cases.)
Canada’s H1N1 rate was almost 15 times the global average—23.7 lab-confirmed cases per 100,000 people, compared to an international average of 1.6 cases per 100,000, according to the WHO data. Canada’s per capita rate was double that of the U.S. and 2.5 times that of Mexico, where the pandemic is thought to have started.
Canada’s H1N1 death rate was 10 times the international average: 7.4 deaths per 10 million people, versus 0.7 globally.
It’s not clear why Canadian H1N1 rates are so high. One possibility is that Canadian medical authorities have simply sent more cases to labs for testing. But the data also suggests another possible factor: Canada’s high concentration of hog farms.
It just so happens that Canada has the world’s eighth-highest number of pigs per capita—almost 15 million pigs, or about one for every two Canadians. And an analysis of international flu data shows that H1N1 rates have strong correlations with hog farming.
In Mexico, where it probably all started, there was a moderate, statistically significant 46-percent correlation between confirmed per capita H1N1 cases in all of the country’s 32 states and its federal district and the number of pigs per capita in those states. That’s according to the data as of July 2, the date the Pan American Health Organization stopped publishing the breakdown of flu cases within countries of the Americas.
(Correlation measures the strength of the relationship between two groups of data. A correlation of 30 to 50 percent is generally considered to be moderate, 50 to 70 percent is strong, while 70 percent or higher is very strong.)
Yucatán was the Mexican state with the highest rate of H1N1 cases per capita: 92 per 100,000 people. It’s also one of the country’s hog-farming hubs, with the most pigs per capita of any state, more than one for every two people.
Argentina had the world’s highest per capita death rate from H1N1, with 15 deaths per 10 million people, or 20 times the world average of 0.7 deaths. In Argentina’s 24 provinces and its capital district, there was a 70-percent correlation between the per capita death rate and the ratio of pigs to people.
The Argentinean province that had the highest death rate was Santa Fe, with 130 H1N1 deaths per 10 million people. Santa Fe also happens to have Argentina’s highest ratio of pigs to people.
And those countries aren’t the only ones where there’s apparently a relationship between the pandemic and hog farming. Among the 39 countries and dependencies in the Americas that had reported H1N1 cases as of July 6, there was a 51-percent correlation between H1N1 cases per capita and the number of pigs per capita.
Globally, the 20 countries with the most pigs per capita had a per-capita H1N1 rate of 5.5 per 100,000—more than 3.3 times the international average of 1.6 cases. As well, their per capita death rate from H1N1 was 2.5 per 10 million, or more than triple the international average of 0.7.
“This is a very serious concern,” said Bob Martin, who headed the Washington, D.C.–based Pew Commission on Industrial Farm Animal Production, when told about the Georgia Straight’s data analysis. “It’s just another step in showing what serious impacts these large-scale swine operations can have.”
Martin’s commission released a study last year that said workers in large farms, and their neighbours, have high rates of asthma and other respiratory illnesses due to manure runoff and emissions like ammonia and fine-particle pollution. Respiratory illness makes people more vulnerable to H1N1, he said.
A high portion of H1N1 hospitalizations and deaths have occurred among people with an additional medical condition like asthma or a compromised immune system.
In an initial story in July, the Straight reported that strong correlations exist between per capita H1N1 rates and the number of pigs per person within B.C.’s five health regions and in each of Canada’s provinces.
As of July 8, Manitoba, the country’s hog-farming capital, with 2.4 pigs per person, had three times as many H1N1 hospitalizations per capita as the Canadian average and 3.7 times as many deaths per capita.
The international data puts the high Manitoba numbers into even starker perspective. Manitoba’s per-capita H1N1 rate, 65 per 100,000 people, was 40 times higher the international average and far worse than that of the country with the highest rate in the world, Chile, which had 44 cases per 100,000.
Manitoba’s death rate—41 per 10 million people—was 60 times the global average and nearly three times that of Argentina, the worst-hit country in the world in terms of deaths.
So far, Canadian public-health officials have said the flu pandemic is spreading mostly randomly, though they acknowledge it has hit some vulnerable populations harder, especially those with respiratory problems, aboriginal people, and pregnant women. Most scientists believe H1N1 originated on a huge Mexican factory pig farm, then spread between people around the world.
In Canadian aboriginal communities, H1N1 is thought to be worse because of poor health care and overcrowding. Indeed, the data confirms that Native people have been hit harder and need extra resources to deal with H1N1. The per capita number of H1N1 cases in each province had a very strong 87-percent correlation with the per capita number of aboriginal people.
That’s even higher than the 77-percent correlation between per capita H1N1 cases and the per capita number of pigs in the 10 provinces.
However, when it comes to more serious H1N1 cases that involved hospitalization and death, the correlations were stronger for hog farming. There was a 44-percent correlation between per capita H1N1 hospitalization rates and the number of aboriginal people per capita in each province, compared to a 72-percent correlation between hospitalization rates and the per capita number of pigs in each province.
H1N1 deaths per capita had an 82-percent correlation with the percentage of aboriginal people in each province, but had an even stronger 89-percent correlation with the number of pigs per capita.
“I hope the World Health Organization will start looking at the same data you’re looking at,” the Pew Commission’s Martin said in a phone interview.