Drug Company Money
To Accept or Not to Accept?
Is That the Question?

by Rosanna Baraldi

In Toronto on May 29 1997, members of DES Action attended a panel discussion on the funding of women’s health groups by drug companies. All kinds of unexpected partnerships are being formed nowadays, and the question arises of whether we should be looking for funding from pharmaceutical multinationals. Many people feel that the private sector should be doing its share to help improve the welfare of society as a whole. But is funding community groups selected by the industry itself the best way to go about it? As government involvement is gradually cut back, isn’t there a risk that women’s groups critical of the industry, who question the overmedicalization of sexual and reproductive health and the natural stages of life, will eventually weaken and even disappear?

DES Action Canada has decided to take a hard line on this and categorically says no to any form of alliance with the pharmaceutical industry. Too many people exposed to DES still suffer from the iatrogenic effects of an ineffective, poorly tested drug. Furthermore, the irresponsible actions of the drug companies that marketed, advertised and profited from the sale of diethylstilbestrol are proof of the dangerous laissez-faire attitude that has not disappeared over time. The medical literature regularly reports on problem drugs, and the industry does not react until it has its back against the wall.

Yet at a time of budget cuts, many organizations are not turning down money from drug companies. What are we to think? Before dealing directly with the question, let’s let the facts speak for themselves so we can get a better idea of the special nature of the pharmaceutical market.

Pharmaceutical Industry: Myths and Well-Kept Secrets
The pharmaceutical industry is not an industry like any other. First, let’s not mince words: its profits are exorbitant, even obscene. In 1992, one of the worst years of the recent recession, while giants like General Motors (the largest U.S. corporation in terms of sales), Ford and IBM, to name but a few, recorded net losses of US$23.5, $7.4 and $5.0 billion respectively, multinational drug companies like Merck, Bristol-Myers Squibb and American Home Products posted profit margins of 20.4%, 17% and 19%. This information is drawn from the companies’ annual reports, and marketing costs and executives’ salaries have been deducted from the profit figures (Lauzon, 1993).

Second, on the chessboard of the private marketplace of illness and health, the drug industry occupies a strategic position and skillfully pulls many strings in the corridors of power. As the supplier of physicians’ main means of treatment, it has developed tried and true seduction methods over the years: paying for doctors’ professional development, conferences, symposiums, meetings, trips, gourmet meals, equipment-not to mention a good part of the medical research conducted in public institutions.

A rich, prosperous, leading-edge sector, it is courted by governments which, especially in times of economic recession, must try to attract investors. Although it is subject to a drug-approval process and government regulations that it considers to be cumbersome and inefficient, it benefits from unprecedented protection: protection related to "trade secrets," a key consideration in the setting of drug prices; a lack of transparency of the drug-approval process, from which critics are generally excluded, and where people with conflicts of interest, who have been co-opted by the companies, are often included; shortcomings of regulations respecting manufacturer’s liability, and so on.

Last, the pharmaceutical sector works according to the American model of competition, where the law is survival of the fittest, without regard to ethics. While the industry justifies the high cost of drugs by the years of research, effort and money needed to develop a new product, it easy to see that drug company spending on advertising, marketing and all sorts of promotion far outstrip the industry’s investments in research and development. In Canada, in 1992, drug companies spent twice as much on advertising as on research; for each dollar spent to buy a drug, 20 cents (or 20%) went to cover the costs of newspaper ads, sales representatives, free samples and posh conventions for doctors and pharmacists.

The companies have many strategies for co-opting health professionals, and not all of them are in good taste. For instance, in April 1993, Canadian Press reported that in 1990, Bristol-Myers Squibb offered a computer as a bonus to any physician who prescribed the drug Capoten to 10 or more patients. The important thing to remember here is that these astronomical promotional costs are being absorbed by the community, and they have a significant impact on public health-care costs. Plus, as everyone knows, the government (through the public health-care system paid for by tax dollars) has become a big pharmaceutical customer (Lauzon, 1993).

It should also be pointed out that the pharmaceutical sector, the prime sponsor of medical research in Canada not only profits enormously, in developing new products, from the technical and human resources and facilities of the public system, but also has a major influence on research objectives and priorities (we will come back to this later). But when the time comes to reap the profits from the sale of new products, there is no question of sharing. Moreover, when the exorbitant prices of new drugs, like those for AIDS, for example, are criticized, the companies cite the high cost of investing in research and the fact that the market is “small.” On this point, let’s look at what Barbara Mintzes (currently a PhD student in epidemiology at University of British Columbia) has to say. She noted that while, from the companies’ point of view, the market is limited to the wealthy countries of North America and Europe, which will find the means to provide patients with these drugs, we must not forget that the AIDS epidemic is wreaking havoc in Asia and decimating entire populations in Africa.

Panel Discussion on Funding of Community Groups by the Pharmaceutical Industry: A Step in the Right Direction
The goal of the discussions in May, organized chiefly by the National Network on Environments and Women’s Health at York University and DES Action Canada, was to promote discussion and debate on the thorny question of the funding of community groups by pharmaceutical companies. Four speakers were invited to share their views on “Ethical Issues in Women’s Health: The Delicate Business of Funding from Drug Companies” with about 60 participants: Barbara Mintzes, who worked for many years with Health Action International (HAI) and is still involved with their activities, taking a critical look at issues concerning drug companies; Dr Joel Lexchin, emergency physician and author of a number of papers on the pharmaceutical industry; Darian Taylor, co-founder of the Toronto group Voices of Positive Women, a community group that works with women living with HIV or AIDS, which has accepted funding from drug companies; and Harriet Simand, co-founder of DES Action Canada, which, as we have mentioned, refuses on principle to accept money from drug companies.

By bringing together people who represent these various points of view, and especially someone from a community group who would agree to speak publicly about accepting money from pharmaceutical companies, thus providing the ingredients for a real debate, the organizers of the evening took a step in the right direction. Darian Taylor’s talk was very enlightening, reflecting the many dimensions of the funding question and an acute awareness of the realities of the women’s community health movement. By contrasting what she said with the critical analyses of the other speakers, we can begin to get to the bottom of the thorny question of the funding of community groups by multinational drug companies, and separate the issues and problems that too often get mixed up together.

Why Take Money from the Drug Industry?
The first point Darian Taylor made in her talk about why Voices of Positive Women accepted funding from the pharmaceutical industry has to do with the specific nature of AIDS. AIDS is still considered to be a fatal disease, and people who have it are convinced that their survival depends on the drugs they take and others that will be developed in future.

The women’s self-help group she founded has its roots in the activism typical of the AIDS issue, not of the women’s health movement. While women have organized to fight the overmedicalization of the natural stages of life and to reclaim their bodies, the first AIDS activists worked to establish close collaboration with the pharmaceutical industry, encourage research into new drugs by taking part in large numbers in clinical trials and exerting pressure to have still-experimental drugs made available to people who need them. As Darian Taylor put it: People with AIDS don’t want to die. At the same time, she briefly outlined the situation of women with AIDS, and it was not easy to listen to. Marginalized, stigmatized, isolated, poor, suffering physically and psychologically: the women supported by Voices of Positive Women have enormous needs that the organization simply cannot afford to meet. Their needs are urgent and daily. Money from the drug industry has enabled the organization to support women in extreme distress. Yet despite the collaboration between AIDS activists and the pharmaceutical industry, and despite the fact that Voices of Positive Women has accepted funding directly from drug companies, Darian Taylor was far from dogmatic. On the contrary, she often emphasized the differences between the women’s health movement and the fight against AIDS, and supported women’s demands regarding overmedicalization.

She also spoke about the hesitations of the AIDS Committee of Toronto, which had to deal with the question of how best to manage the funding provided by the pharmaceutical industry. For example, she mentioned the extremely interesting idea of creating a central body to collect drug industry funding and distribute it fairly and anonymously. The money given to a particular organization would come from a pool, rather than from a well-identified company. This system would counter the influence of pharmaceutical companies, which could seek to strengthen the organizations they choose to fund depending on their interests and leave other organizations, which might either directly or symbolically benefit them less, to fend for themselves.

Why Refuse Drug Company Money?
While the AIDS movement may have some questions about accepting funding from the pharmaceutical industry, women’s groups fighting the medicalization of women’s sexuality and of the natural aging process find themselves in an even more delicate position.

As Barbara Mintzes pointed out, hormone treatments for women can start at puberty and continue until death, from contraception, pregnancy and infertility through to hormone-replacement therapy for menopause. Drug companies are looking for universal technical solutions - in the form of marketable products - to physical and psychological symptoms, and even, if you look at the advertising, to psychosocial problems. Pharmaceutical industry advertising that Barbara Mintzes showed us reinforces the technological bias and has a definite influence on how we think. As Joel Lexchin wrote recently, "Doctors attach a great deal of importance to the advertising they receive, and it is this advertising that determines what they prescribe and how often."

Isn’t it symptomatic that the first question a woman asks herself when she reaches menopause is whether she should take hormones or not? It is no longer enough to think about various ways to stay healthy and get through a passing phase that may be difficult physically, but whether to take hormones (which, mistakenly, promises “staying young”). This is a major bias that illustrates perfectly the huge influence of the drug industry: the first question women ask themselves focusses on the existence of products - technologies - that are highly profitable to the drug industry. And it is worth remembering that, overall, about two thirds of all prescriptions are written for women, which is obviously too much.

But the subtle and not so subtle influence of the pharmaceutical market is not limited to advertising. By revealing a series of alarming biases in professional development training programs for doctors funded by the industry, and in the objectives of medical research, also funded by the industry, Joel Lexchin showed how vigilant we must be in any alliance with it.

The influence is often subtle but well presented and persistent: funding for conferences, symposiums and lectures only if they are tied to the potential sale of products; bias in the selection of speakers invited, thus limiting criticism; creation of a cordial atmosphere that encourages trust and reciprocity, since the industry, through its generous contributions, “helps” doctors further their training (drug company representatives become like friends); funding for research that aims to demonstrate the superiority of a company’s products to the detriment of research that might be more useful clinically; funding only for studies that might lead to the development of a new product; failure to publish results of research unfavourable to the sponsor, etc.

Moreover, and this is where Joel Lexchin directly addresses the concerns expressed by Harriet Simand, it is essential to point out that all drug testing is done by the pharmaceutical industry itself, that the research results submitted to government authorities for product approval are kept secret, that the mechanisms for post-marketing monitoring of drugs are extremely lax, as are the measures for promoting adequate manufacturer’s liability. Summing up the highlights of the history of DES (put on the market without rigorous testing of effectiveness or safety) - DES found ineffective in first controlled study; intensive advertising extended to all pregnancies ("to make healthy babies even healthier".) - Harriet revealed the cynicism of the powerful pharmaceutical industry.

In fact, the drug industry has taken absolutely no steps to help those exposed to DES, and still does not conduct serious post-marketing monitoring of drugs; moreover, long-term toxicity is still a fuzzy concept that has not been defined rigorously in concrete terms. If the drug companies are serious about their role as good corporate citizens, then you would expect them to redress situations of marketed drugs that turned out to be harmful, rather than only providing token funding to groups which will not be critical of the industry.

For Greater Social Justice and Solidarity: Why Not Blind Funding Out of a Tax on Profits? The evening’s organizers asked us to think about concrete solutions. We have two possibilities open to us. As things now stand, each organization, in isolation, accepts or refuses proposals from the drug industry. But the team at York is developing guidelines which will be essential in raising consciousness about ethical considerations. Over the long term, however, if we do not go beyond the guidelines, the influence of the drug industry may well become overwhelming (as it is in the case of ongoing training for doctors or medical research) and have a considerable negative impact on our society.

The logical outcome of the debate last month would be to continue working together and, as one of the participants suggested, to try to socialize the industry. In the course of the discussion, Barbara Mintzes and Joel Lexchin again brought up the proposal, often seen in the public-health literature, to establish a compulsory tax on drug companies (a percentage of profits, for example) that would be used to set up an independent drug-testing agency. This same kind of structure could also be established to distribute funds back into the community. Darian Taylor’s idea of an “independent, anonymous pool” could be well worth looking at. It could be interesting to draw up an action plan to accompany the York guidelines.

Drugs are not consumer goods like any other. Given society’s significant involvement in the manufacture and distribution of pharmaceuticals, should society not also have free use of a share of the exorbitant profits reaped by the drug companies