Should there be drug advertising?

A retired hippie, Richard Smith (now editor of the BMJ), makes a case for

This is the piece I've dreaded writing. I grew old the day John Lennon died. Today I grow very old. I'm 49 - as ancient in your minds as Winston Churchill, nylon stockings, and spitting in the street. But if I'm old enough to preach to you about the need to include drug advertising in the BMJ I must be as old as them. I want to make my case - in part - by telling you my story. I started from where you may be now. It is the fate of revolutionaries to turn into the people they despise, and I'm the living proof - but I still think I'm right.

Root of most evil

While at school in south London I was a communist. I sometimes imagine myself explaining what that means to my grandchildren, which, as far as I know, I don't yet have. It will seem as strange as having believed in the phlogiston theory. I do have the excuse that one reason I joined the communists was to meet girls and even kiss them (that's all we did before sexual intercourse was famously invented in Hull in 1963 and even later in south London). But I did care passionately about world poverty and injustice, racism, and colonialism. I read Regis Debray's notes on guerilla warfare, learning how to keep my gun dry in the jungle. I believed that big business - as symbolised par excellence by pharmaceutical companies - was the root of most evil.

At medical school I swept into political power on a slogan that would have made Peter Mandelson envious: "Don't be thick, vote for Dick." I sat on committees with other rebellious youths like Gordon Brown, illustrating that this "growing old thing" affects the best and the brightest. I edited Synapse, the medical school magazine - renaming it boldly Prolapse - and earned a tiny place in its history by being the first editor to print the word "fuck."

Later at the BMJ I wrote articles on alcohol policy and asked a leader of the advertising industry to "give me one reason why all advertising shouldn't be banned." I also wrote on unemployment and health and tried my hand at some economics, assuming that the government could if it wanted to fix unemployment.

The point I'm making is that I understand something of the position of those who think that the studentBMJ should not carry advertising from the pharmaceutical industry. The adverts come from business monsters who are corrupt and the source of much of the injustice in the world. The advertisements cannot be believed and distort knowledge and prescribing patters-and they simply aren't necessary. So ban them.

My transition

The most dramatic moment in my transition to a different way of thinking about business and economics came in November 1989. I was doing the Sloan programme ("an MBA for the middle aged") at the Stanford Graduate School of Business in California. I was upstairs in our student house doing my homework on microeconomics when my wife called me. I went down and saw television pictures of the Berlin Wall being pulled down.

I learnt in economics that there are two broad options for economies - planned and market. The collapse of the planned economies of eastern Europe ended any serious belief in planned economies. Markets must be regulated and create their own problems, but they are essentially the only option for running economies. The "third way" is nothing qualitatively different: it's simply a form of a regulated market economy.

Pharmaceutical companies illustrate the power of market economies. It's virtually impossible to think of an important drug that wasn't developed by the industry, and even those that go back a long way - like digitalis - are manufactured by the industry in a pure form so that they can be used therapeutically. The profit motive has given doctors an array of effective interventions that hardly existed before the 1950s.

And advertising is an important part of a market economy. It is needed to promote competition and is essential for allowing new and superior products to come through. It must be regulated, and it is-by British and European legislation, by a code of practice committee, and by the Advertising Standards Authority.

Advertising is only part of the story

It's true that advertising tells only part of the story, but so do most articles in newspapers and - it must be said - the BMJ. We might aspire to complete objectivity but we never reach it. The beauty of advertising is that everybody knows that it's biased. My 10 year old daughter knows that, and so do medical students. They have been bombarded by advertising all their lives and will continue to be. They need to learn to interpret it, and where better to learn than the studentBMJ. The websites of the BMJ and studentBMJ contain many pieces on problems with advertising and advice on how to deal with promotions from pharmaceutical companies.

So there could be a case for including advertising in the studentBMJ even if we weren't paid for it - but of course we are. We can use that money to underwrite some of the high costs of the journal and importantly buy our editorial independence. Making a profit is the biggest single guarantee of editorial independence.

Perhaps the clinching argument for advertising comes courtesy of the web. It has allowed publications to give readers the choice of receiving material free with advertising or paying for it without advertising. Surprise, surprise almost nobody pays.

Richard Smith, editor, BMJ
rsmith@bmj.com

Should there be drug advertising?

A human rights campaigner, Rhona MacDonald (editor of the studentBMJ), makes a case against

Perhaps it is just that I am not as old as Richard Smith and have not yet had time to be corrupted by market economies, but I still care passionately about world poverty, injustice, racism, and colonialism. To me drug companies are still the "root of most evil." Am I just being naive and idealistic? I don't think so.

I worked in Bangladesh for a while. What I saw there broke my heart and I vowed that I would make it my life's mission to contribute something to help combat world poverty. Engraved in my memory is something I witnessed there that was totally perverse. Sugar coated vitamin pills were being promoted by drug companies in a way which made some of the poorest people in the world think that they were not doing the best for their children. So they exchanged a day's wages for a useless piece of trash which would not be allowed to go on sale in Britain. I also worked in an orphanage in Romania for four consecutive "holidays." The drug companies' donations of antibiotics and vitamins were all out of date.

I won't be bribed

As a hospital doctor, I never went to any of the drug companies' nights out. It was standard practice where I worked that if you wanted a night out, you just found a drug rep who could take you so you didn't need to pay. Because the drug companies saved money by not taking me, I asked them to give the money to charity instead. They never did. I never ate the drug companies' sandwich lunches even though I had to go to their educational talks as part of my continuing professional development. I didn't have time to go to the canteen which meant I had to starve all day.

Why was I so against even eating an innocent sandwich, which had been tainted by a drug company? Because this is the start of the slippery slope. Drug companies will do anything to hook doctors and then pull them in. They even try hard to give the illusion that they actually care about people in the Third World. Do not be fooled. Profit motivates everything that drug companies do. For example, the drug company Roche funds Sight and Life, a humanitarian initiative to combat vitamin A deficiency. However, Roche was recently discovered to be the leader of a conspiracy to set vitamin prices and, along with three other drug companies, had to pay nearly $1bn (£714m) in criminal fines. A Roche executive was sentenced to five months in jail.

Drug firms exploit people

Drug companies exploit people in developing countries. Firstly, they test drugs on poor people who will never benefit from them. Secondly, they refuse to market products that would save lives but would not rake in profits. For example, eflornithine is the only agent effective against African sleeping sickness, which claims thousands of lives a year. However, for profit reasons, Hoechst Marion Roussel stopped its production. It recently found that it could slow the production of unwanted facial hair in women, so suddenly the drug is commercially viable again. Finally, drug companies refuse to allow poor countries to make cheap generic versions of essential medicines. The industry fiercely guards its patents and has the support of the Word Trade Organisation's agreements on intellectual property rights. Like many campaigners for human rights, I was delighted at last month's historic decision to drop all charges against the South African government for breaking these patency agreements.

Funding for research

Drug companies say that they would not be able to develop new drugs to help patients in the West if poor countries could make cheaper equivalents. What is the morality behind saving a few lives against saving the lives of thousands? At the end of the day it all comes down to money, and who can afford to pay for treatment.

I have a rare, progressive illness for which there is no cure. I would much rather drug companies spent money developing drugs which will save the lives of millions in developing countries than a drug that may help to save my own life.

The money saved by stopping the bribing of doctors and the placing of drug advertisments in medical journals could easily be used for developing drugs for use in developing countries.

I recently accepted an invitation for selected journalists to lunch with the Association of the British Pharmaceutical Industry. Don't worry, I wasn't going to eat their food, but it was just after the South African decision and I did want to hear what the association had to say. It was in one of London's poshest hotels (I didn't realise this and turned up in my jeans!), and everyone except me was tucking into a three course meal. The association will not allow me to quote what was said, but I was alone in my disapproval of the patency agreement, the bribing of doctors, and the way in which those present were talking about the African people (in between mouthfuls of salmon). The cost of the lunch would probably have been enough to supply antibiotics to South Africa for a whole month. As I left the dining room, a Brazilian waiter came running after me to thank me for what I had said. So, should the studentBMJ carry drug advertisements? Definitely not, if the decision was mine to make. I have come to accept that the BMJ needs drug advertisements to be independent. However, the studentBMJ is never likely to be independent as your BMA subscription doese not fund the studentBMJ. We rely on the BMJ to keep us going. Since the BMJ has drug advertisements, I do not see why the studentBMJ should be tainted as well.

Rhona MacDonald, editor, studentBMJ
Email: rmacdonald@bmj.com


studentBMJ 2001;09:171-216 June ISSN 0966-6494