Tuesday, August 20, 2019

India's Drug Pushers and Dope Peddlars

Two of India’s biggest drug companies are alleged to be giving inducements to “quack” doctors of gifts and cash to encourage them to prescribe vast amounts of antibiotics, fuelling the rise of drug-resistant superbugs around the world. India’s unqualified doctors – who are often from poor rural areas and slums – earn so little that these incentives can raise their monthly income by as much as a quarter.

Sun Pharma is the largest drug manufacturer in India, with more than £3bn revenue in 2018, and its products are used by the NHS. NHS rules do not prevent it buying from companies that give inducements to doctors, as long as none are given in the British supply chain. The NHS also buys devices from Abbott Laboratories, a US company that pulled in more than £24bn in revenue last year. Its Indian subsidiary, Abbott India, is the second-biggest pharmaceutical business in the country.

It is illegal to sell antibiotics to quack doctors in most parts of India, but the law is rarely enforced. The so-called quacks, who are sometimes the only healthcare provider in their impoverished communities, often go on to prescribe antibiotics incorrectly. By offering incomplete or simply unnecessary treatments, they unwittingly speed up the creation of superbugs that kill tens of thousands of babies in India alone each year. India is a centre of the antibiotics resistance crisis. Superbugs kill at least 58,000 babies every year and Indian doctors warn they regularly see patients with “pan-resistant” infections; those resistant to all available drugs. 

In theory, India offers free healthcare to its poorest citizens, but a recent report from the CDDEP found a shortfall of 600,000 government doctors and two million nurses. Many people therefore depend on India’s more than 2.5 million quack doctors, which includes those who practise traditional medicine, such as Ayurveda, homeopathy and naturopathy, and those with no medical training at all. They vastly outnumber the one million private or government doctors trained in scientific medicine. Many patients do not realise the doctor they visit has no recognised qualifications.

A sales representative admitted that sales representatives promoted antibiotics based on how much profit they would make, rather than medical evidence. He said: “Now, the point is not about whether they work or not. The point is: where is the market? Where is the big market?...So it is not about the efficacy part, it is about how good I can grab the particular market and then penetrate into that market.” The salesman described quacks as an “easy” market for antibiotics and their main target for sales. Professional doctors needed to be convinced of how safe and effective a drug is, whereas quacks often required no explanations, only incentives, he said.
The aggressive marketing is in part down to their sales targets: Sun Pharma sales representatives earn bonuses if they sell more than 300,000 rupees (about £3,440) worth of antibiotics and painkillers every month.
Dr Meenakshi Gautham, a researcher from the London School of Hygiene and Tropical Medicine, based in India, has interviewed quacks, also called informal providers, for more than a decade and concludes they are being increasingly targeted by pharmaceutical companies who aggressively market antibiotics. 
“I have had pharmaceutical representatives tell me in some areas that if they have targets to sell 100,000 rupees [£1,150] worth of antibiotics, 80,000 comes from selling to informal providers, and 20,000 from formal doctors,” she said. Her research shows that most quacks, as well as private doctors, get all their information about antibiotics from sales representatives and drug companies, rather than independent sources. Companies will host fully catered conferences for quacks with paid lectures from private doctors on which antibiotics to prescribe, she said. “There is a strong push coming from the pharmaceutical industry,” Gautham said. “That push takes the form of very aggressive promotion of antibiotics, especially in rural markets, because these represent huge turnovers for those companies that manufacture and market antibiotics..."

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