Expensive lunch

Michael Westerhaus looks at the implications of free lunches and pharmaceutical gifting of healthcare professionals

As a young child, I remember my fascination with the endless offers for free items on breakfast cereal boxes. The word “free” hypnotised me. My mum, however, knew that free meant someone, somewhere, would pay for it. Thus, one of her favourite mantras was, “Nothing’s free.”

Close encounters

My mum’s words haunted me just months ago in the most unlikely of places—an HIV clinic in an urban US setting, where I was rotating as a medical student. During the morning of my first day in the clinic, I listened to the stories of patients presenting for HIV check-ups. Many of the patients shared chronicles of struggling to survive on incomes below the poverty line, working long hours for a meager income, and labouring to maintain adequate housing and nutrition.

Humbled by the morning narratives of struggle and suffering recounted by patients, I was unprepared for the shock awaiting me at lunchtime that day. Entering the clinic’s conference room to join the staff of physicians, nurses, pharmacists, social workers, and HIV prevention specialists, I was faced with the aroma and sight of an extravagant Olive Garden lunch, including chicken parmesan, Caesar salad, spaghetti and meatballs, and a tray of rich tiramisu. All the food had been provided by a pharmaceutical representative, who was present to answer questions about her company’s latest HIV drug. Reproach for the episode unfolding before me didn’t, however, prevent me from filling a plate.

As I shamefully seated myself with a full plate of food in hand, a clinic staff member leaned over and whispered that “free lunch” was provided every day of the week except Tuesday. As the pharmaceutical representative extolled the virtues of her company’s products, guilt swallowed me with every bite of the feast. How could it be right that I would enjoy lunches from companies who have resisted lowering prices to make these life saving drugs accessible to the millions dying of AIDS globally? I imagined the conference room full of the patients we had seen that morning and wondered how they would react watching us eat free food, subsidised by drug companies to which they pay hard earned dollars.

Close encounters between pharmaceutical representatives and the healthcare staff persisted throughout the rotation. Catalogues of medical textbooks were presented for doctors to peruse and select “free educational materials.” Pharmaceutical representatives organised festive outings for the staff at a local pub. Disturbing irony struck when a delegation of government leaders from Botswana and Ethiopia visited the clinic. A drug company representative gifted each visitor with handbags full of free goodies and, of course, provided lunch. In both Botswana and Ethiopia, enormous suffering has unfolded in recent years due to deaths from AIDS, in part due to the lack of affordable treatment. The same companies that have relentlessly constructed obstacles to equitable HIV drug provision in Africa were now gifting African foreign dignitaries.

Expensive lunch

To gauge the magnitude of financial resources spent on giving free lunches to healthcare staff at this clinic, I tabulated the total cost for that single Olive Garden lunch based on the large group takeaway menu prices advertised—$194 (£107; a157; box).¹ Throughout the one month rotation, lunches each day were equally extravagant and multiplying this number by four would give a fair estimate of the weekly spend—$776. Multiplying by 52 results in a staggering $40352 spent a year on free lunch for this clinic’s healthcare staff. This particular metropolitan area has 18 HIV clinics, meaning that if all clinics accepted the lunches from drug companies, a potential $726000 could be spent in a year on free lunches in the HIV clinics of one metropolitan area.² At a time when both 88% of people in need of antiretroviral therapy worldwide lack access to these life saving drugs and poor HIV positive patients in the United States must pay for increasingly greater portions of medication prices, lavish expenditures for doctors’ free lunches cannot be justified.³

Drug companies spend an average of 35% of their income on marketing and administration each year.⁴Pharmaceutical marketing expenditures have been estimated to be $12bn-$15bn a year in the US, which includes $8000-$15000 spent on marketing to each US physician.⁵ A portion of these marketing costs go towards free meals and other gifts such as medical textbooks, tickets to entertainment events, free travel, and company sponsored “happy hours,” which are organised, offered, and peddled by 88000 drug representatives each day in the US.⁴ It would seem to make business sense that eliminating the cost of these free lunches and other gifts could lower drug prices for patients. The solution here seems simple: stop the free lunches and other gifts to healthcare workers.

Counter arguments

Counter arguments emphasise the educational utility of lunchtime visits by pharmaceutical representatives. These claims argue that contact between drug company representatives and healthcare staff allows for the exchange of information regarding the use of specific drugs and the latest pharmaceutical research. In arguing this position, the Pharmaceutical Research and Manufacturers of America, which lobbies for large drug companies, has recently stated, “[Interactions between pharmaceutical representatives and healthcare professionals] play a valuable role in helping to remove the stigma associated with some diseases; educate physicians about available treatments; help patients find the right medicine… and raise physician awareness of the most recent clinical practice guidelines and most recent medical technology.”⁶ On a practical level, healthcare staff may argue that without the pens, pads, highlighters, etc, provided by drug companies, clinics would need to make these purchases out of their own budgets.

We must admit though, the free lunches and other gifts are a matter of comfort and not learning. Among healthcare staff, a sentiment of entitlement to free gifts underpins the perpetuation of this practice. Drug companies know how to satisfy these feelings of entitlement through the provision of a free lunch. Furthermore, the quality of information provided by pharmaceutical representatives must be questioned. How can we expect drug company presentations to be free of bias when the aim is to sell a product and make a profit? Education of healthcare workers should be the full responsibility of the medical profession.

Some healthcare workers may deny that giving gifts has any impact upon them. However, research has shown that gifts do indeed influence doctors’ behaviour, either consciously or subconsciously through the social forces that encourage reciprocity after the giving of a gift.^57 In the case of free lunches, doctors were more likely to request adding medications to a formulary in direct relation to the frequency of meals provided by particular drug companies.^89 Thus, feelings of entitlement and the pressures of gift exchange co-conspire to cater for the interests of the pharmaceutical industry, leaving the voices and interests of patients largely silenced.

Reclaiming integrity

If we are going to advocate full heartedly for our patients, we must also level critiques at ourselves. We must realise that medications bankrupt patients, in part, because of decisions we make as healthcare professionals. Medical professionals, including students, have a powerful opportunity to refuse participation, on a number of levels, in the system of gifting that contributes to exorbitant prices for pharmaceutical products. On a day to day basis, healthcare workers can oppose free lunches by bringing packed lunches or buying their own meals. Medical students, residents, and doctors can participate in advocacy efforts, such as No Free Lunch or the American Medical Student Association’s Pharmfree campaign, to diminish the gifting relationship with the pharmaceutical industry. Doctors can choose to prescribe available generic drugs, especially for brand name drugs manufactured by pharmaceutical com­panies that give gifts to healthcare workers.

Also, clinic and hospital administrations can be challenged to implement policies that forbid the giving of gifts by pharmaceutical companies. Medical schools and residency programmes can devote curricular time to discussions that encompass pharmaceutical marketing strategies, professional guidelines for dealing with gifts, and research on the positive and negative impacts of gifts, thereby following in the steps of programmes such as the one developed by Wake Forest.¹⁰ On a structural level, doctors and nurses can start asking why drugs for their patients are so exorbitantly priced. Finally, health professionals can advocate for government and business policies that promote equal access to drugs by curbing excessive drug prices set by an industry that routinely achieves a profit margin of 17%.¹¹ In both small and large ways, the self serving system of the pharmaceutical industry giving gifts that privileges profit over people can be challenged and changed.

My mum was right. Nothing is free in this world, including the innumerable lunches that pharmaceutical companies provide throughout the US each day. In this case, it is the patients who pay with their money and lives for free lunches. Healthcare workers need to choose integrity and refuse free gifts from the pharmaceutical world. Only then can we say we are fully working towards providing the best, and most just, health care possible for our patients.

Michael J Westerhaus, fourth year medical student and masters student in medical anthropology, Harvard Medical School and Harvard Graduate School of Arts and Sciences
Email: michael_westerhaus@student.hms.harvard.edu


studentBMJ 2005;13:309-352 September ISSN 0966-6494

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