Doctors dole out drugs for gifts from pill-pushers

Coffee makers, cookware and vacuum cleaners are among the many gifts for Indian doctors listed in a sales-strategy guide for pharmaceuticals company Abbott Laboratories.

Vinay Kulkarni, a doctor, examines the eyes of a patient inside his clinic in Pune.

MUMBAI // Sales representatives for Abbott Laboratories' Indian subsidiaries know what it takes to get a doctor to prescribe the drugs they market - a coffee maker, perhaps, or some cookware, or maybe a vacuum cleaner.

These are among the many gifts for doctors listed in an Abbott sales-strategy guide for the second quarter of 2011. As laid out explicitly in the guide, doctors who pledge to prescribe Abbott's branded drugs, or who have already prescribed certain amounts, can expect some of these items in return.

Consider the guide's entry for Nupod, an Abbott antibiotic generically known as cefpodoxime. It lists a medical textbook, a mosquito repellent and a coffee maker as incentives for doctors.

It also provides a script of the social niceties for clinching the deals. Especially in India's poorer areas, says one Abbott rep, "if you give them a small gift, they are happy".

The Abbott guide is evidence of a larger problem in India. Dozens of doctors, drug representatives and other healthcare insiders said domestic and multinational drug makers routinely shower Indian doctors with gifts, trips abroad and cash payments disguised as consultancy or other types of fees.

"Indian CRM", or customer-relationship management, is what industry insiders call this system of inducements. None of the doctors or reps who described their participation in this trade would speak on the record.

Under Indian law, doctors are prohibited from accepting cash, gifts or travel from drug companies. But enforcement is rare, and drug makers may lavish gifts on doctors, though their home countries may punish the practice. In a country where doctors often earn less than Dh36,730 a year, it can be an effective strategy.

"Somebody is doing something for you," said a Delhi-based cardiologist. "Obviously you will want to return the favour."

He prescribes more drugs from companies that provided gifts and sent him on paid holidays to Thailand, Hong Kong and elsewhere.

One of those companies, he said, was the India-based Ranbaxy unit of Japan's Daiichi Sankyo.

"We do not sponsor holidays for doctors," a Ranbaxy spokesperson said. "We are viewed as a scientifically and academically orientated company and our promotional activities are built around academics and science."

Chicago-based Abbott said it complied with Indian laws and regulations, adding that company policy forbids employees to "offer or give a sponsorship, gift, meal or entertainment in exchange for an explicit or implicit agreement that Abbott Products will be used, purchased, ordered, recommended or prescribed".

The Indian market is particularly vulnerable to corruption because of intense competition. Until 2005, India flouted drug patents, refusing to rein in domestic copycats of Big Pharma's blockbusters. Brands proliferated. Today, an Indian doctor can choose from among 224 registered brands of the cholesterol-lowering drug atorvastatin, sold by Pfizer as Lipitor in the United States and elsewhere.

Foreign companies that want a piece of this crowded market "have to adapt, or they are not going to survive", said an executive with Biocon, a leading Indian biotech company. The executive said Biocon routinely gives doctors iPads, iPods, mobile phones, "you name it".

A Biocon spokesperson said the executive's statements were "incorrect and absolutely untrue", adding that the company operated "in strict compliance" with the law.

Health experts and some Indian doctors said that as a result of drug companies' tactics, drugs were dangerously overprescribed and expensive brands were prescribed instead of cheap ones.

This can be devastating for patients - physically and financially - in a country where health care is mostly private and unsubsidised, and where 400 million people live on less than Dh4 a day.

At the Amrita Clinic, a private practice in Pune, Maharashtra state, physician Vinay Kulkarni said he refused to accept gifts from reps, partly because he believes drug makers overcharge for products to recoup marketing expenses. "Ultimately, everything is being paid by the patient," he said.

As Big Pharma has pushed into emerging markets such as India in recent years, companies have been running into trouble with their home-market overseers.

Many top drug makers have warned in recent regulatory filings of potential costs related to charges of corruption in foreign markets.

Last year, Johnson & Johnson agreed to pay US$70 million (Dh257.1m) to settle US charges that it paid bribes and kickbacks to win business in Greece, Iraq, Poland and Romania.

Pfizer recently agreed to pay $60.2m to settle a US government inquiry into its use of illegal payments to win business overseas, including gifts such as mobile phones and tea sets to doctors in China who prescribed the company's products.

Abbott became the leading pharmaceuticals company in India in 2010, when it paid $3.7bn for the branded generics business of Mumbai-based Piramal Healthcare.

Its thousands-strong Indian sales force has helped buoy the parent, as sales in emerging markets rose 23 per cent to $2.59bn in the second quarter of last year - more than twice Abbott's global growth rate.

Prescriptions for Paraxin, a drug for typhoid fever, are rewarded with a hand sanitiser and an antique pen. Prescriptions for Lysupra, a multivitamin supplement, could earn a beaded car-seat cover "for the relaxation when you are travelling".

Scanners and steam irons

Abbott reps said that so far this year, they have doled out, among other things, scanners, steam irons, shoes, stethoscopes and gift vouchers worth more than $100 to doctors - both private and employed by the government.

Amitava Guha, a member of the national working committee of the Federation of Medical and Sales Representatives' Associations of India, worked as a rep for decades, including for Piramal from 1997 to 2008, when he retired.

"Everybody is doing it," he said. "I was doing it when I was in service. They said it is your job to go and give to the doctors."

He said he resisted giving anything but the smallest gifts, such as pens. Today, he said, he receives frequent complaints from reps across the country about the practice. It taints their professional image, he said.

The managing director of a large diabetes clinic in Calcutta said he saw as many as 25 reps a day.

"Whatever you like, they can provide you," the doctor said.

His interview was interrupted when a man squeezed into his office and placed a big yellow box on the table.

"Sir, this is an exquisite casserole set," the visitor said, slipping the doctor a note bearing the brand name Rostar, a cholesterol-lowering medicine from the Mumbai-based Unichem Laboratories.

Unichem did not respond to requests for comment.