Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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"Unbiased evidence based information"? I think not
- Peter Martin (14 September 2007)
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The information of the market place
- Jonathan V. Howell (14 September 2007)
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Partnerships for Drug Promotion
- Eddie Vos (19 September 2007)
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Re: "Unbiased evidence based information"? I think not
- Tim Reed (25 September 2007)
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Peter Martin, Director Harefield, UK, HP4 2QQ
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I have commented in a previous Rapid Response on the claim made by some organisations that they represent the European consumer and the European patient that the evidence for such claims is, to put it kindly, tenuous (http://www.bmj.com/cgi/eletters/334/7600/935#164885). This is particularly true for one of the organisations cited in Magrini and Font's article, Health Action International. The vast majority of the European branch of Health Action International's funding appears to come from Governmental sources, at least as far as can be garnered from their website, the latest disclosure being 2004: http://www.haiweb.org/01_about_finances.htm Membership subscriptions for HAI at just over €5000 are relatively insignificant. HAI funding from patients seems to be around 0.5% and funding from Governments, who might be thought by some to have a vested interest in minimising short term expenditure on medicines, and therefore limiting the information available to patients and potential patients, is more than 87%. The fact that this disclosure of information from HAI is far from complete and two years out of date is perhaps also worthy of comment. It is likely that nobody involved in this debate is free from a potential conflict. The views of Pharmaceutical Industry critics are also value-laden, as is clearly illustrated by the repeated and erroneous conflation of advertising emanating from the Pharmaceutical Industry with the provision of information by the Industry. The two are separate activites, as is acknowledged by Regulatory Agencies across the world. Nevertheless this misleading equation of promotion with information provision is repeated by authors such as Magrini and Font, and uncritically published in journals such as the BMJ. There are conflicts and value judgements on both "sides" of the debate surrounding the question of whether or not patients and consumers should be entitled to request and receive information fom those companies who have researched and produced the medicines they are taking, or that they may wish to consider taking. To suggest otherwise is misleading and self-serving. I should add these are my personal views and not those of my employer, Norgine. Competing interests: Employee of a pharmaceutical company, Norgine. |
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Jonathan V. Howell, Consultant in Public Health West Midlands Specialised Commissioning Team, Edwin House, Second AvenueBurton upon Trent DE14 2WF
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Magrini and Fonts'(1) suggestions do indeed seem sensible if you focus on their principle of providing information to meet patients' needs. Although they discuss direct to consumer advertising the role of drug promotion at an earlier stage may have already influenced the views of the public and patients. The current European legislation on drug promotion does not allow an easy definition of what promotion by a pharmaceutical company before market authorisation might entail. This is of particular concern as this can drive healthcare funding without allowing an adequate assessment of the evidence. Many pharmaceutical companies appear to routinely employ major marketing companies to promote their new drugs in a variety of ways. The recent example of the premature promotion of Herceptin for early breast cancer is reported as being seen as exemplary by the industry and will be widely copied (personal communication). By using major cancer conferences as a place to release the early results from high profile trials it is possible to gain worldwide publicity. This can also be supported by website press releases to inform the stock market, which then means that you have one-sided information freely available in the market place. Other tactics may be used. Guerrilla media tactics may not be a phrase in widespread use in the medical world but it accurately describes the ability of "marketeers" to subtly influence the media. This can give the public biased and emotionally charged information as patients appear on television and in the papers. A Google search on "guerrilla media tactics pharmaceuticals" gives you the simple definition of "Getting more media attention without news". The small patient group in Stoke-on-Trent, "Women Fighting for Herceptin", was heavily supported by one of the world's top ten marketing companies(2). The ensuing national media campaign pushed politicians into supporting the unlicensed use of Herceptin and hence undermined the UK Medicines Act and the role of NICE (National Institute for Health and Clinical)(3). Many healthcare commissioners caved in under the subsequent pressure and agreed early funding. The drive for pharmaceutical company profits is changing the tactics of information use but in the long run this is much more likely to undermine public trust in the industry than it is to help patients. (1) Magrini N, FontM. Direct to consumer advertising of drugs in Europe. BMJ 2007; 335:526 (15 September.) (2)Boseley S. The selling of a wonder drug. The Guardian 2006. (29 March.) (http://www.guardian.co.uk/science/2006/mar/29/medicineandhealth.health) (3) Department of Health. Speech by Rt Hon Patricia Hewitt MP, Secretary of State for Health, 25th October 2005:Breast Cancer Awareness. Especially paragraphs 18 and 21.(http://www.dh.gov.uk/en/News/Speeches/Speecheslist/DH_4121929) Competing interests: JH advised healthcare commissioners about the funding of unlicensed Herceptin. A complaint by him about the promotion of Herceptin was upheld. |
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Eddie Vos, maintains www.health-heart.org Sutton (Qc) Canada J0E 2K0
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Direct to consumer advertising is complex, more insidious
than most of us realize and hard to legislate since stakeholders simply work behind supported organizations, patient's groups or advertising agencies.
Two examples:
1. The 'National Stroke Association' [NSA; stroke.org], ".. enabled by the generous support of .., an elite group of industry partners .."(1). These include statin manufacturers as well as G.E. (1), also owner of the NBC news network (2) with whom NSA also 'partners' in an 'awareness campaign'. Their advertisement is a cute video clip on YouTube entitled Cholesterol and Stroke (3). A hot-dog on a psychiatrist's couch worries about high cholesterol being a risk factor for stroke--yet there is zero scientific evidence for a causal link. The clip ends by showing a pill box reading 'Rx statins'. The danger of such message is that while some statins have shown to reduce ischaemic stroke, at least 2 statins increase haemorrhagic in study populations that, at baseline, virtually excluded the 20 to 25% of patients with strokes that are haemorrhagic [simvastatin, approaching significance in post-hoc HPS, and atorvastatin as a primary endpoint in SPARCL and where the increase was significant (P=<0.025); both studies versus placebo (4). 2. Pfizer, makers of atorvastatin [Lipitor] and 'partnering' with 5 organizations they help finance, publishes MakingTheConnection.ca where they frighten people about cholesterol with morgue or shark images while enticing people with a lottery or golf memorabilia. Unsaid (on all but the home page (5)) is the name of the copyright owner [Pfizer] and the fact that its statin has never saved anybody from early death in a clinical trial or meta-analysis thereof, and this in a disease that ranks number one in mortality world-wide. In Canada, these messages are legal if not mentioning a drug name being 'information-seeking advertising'. No balance or medical journal level caveats are required or given. Supporting the authors of the editorial, 'partnering' with stakeholders will be an eternal struggle to get the non-supporting data published. Even 'information seeking' and 'ask your doctor' ads are vehicles to mislead as the examples above show. vos{at}health-heart.org 1. http://www.stroke.org/site/PageServer?pagename=CAB
Competing interests: None declared |
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Tim Reed, Director Health Action International, Jacob van Lennepkade 334T, Amsterdam 1053NJ, The Netherlands
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Given the competing interests listed by Peter Martin it is not surprising that he has felt compelled on more than one occasion to snipe at Health Action International (HAI), an independent network working to increase access to essential medicines and improve their rational use (‘Unbiased evidence based information"? I think not’ http://www.bmj.com/cgi/eletters/335/7619/526#176485). However, his letter contains such inaccuracies that on this occasion it deserves a response. One glaring inaccuracy in Peter Martin’s piece is that our last declared funding is from 2004, which he suggests would be some foundation for suspicion. However, if he cared to look on HAI’s homepage (www.haiweb.org) he would also find our annual accounts for 2006, being our most recent financial cycle. Suspicion dispelled, I think. Peter Martin points out that our membership fees represent a small part of our funding. HAI is membership based, but our membership fees are on a scale which means the unemployed, those in developing countries, students and so on pay minimal fees or their fees are waived, so the income does not necessarily reflect our membership. But even if it did, if he cares to again visit our homepage, he would see that member organisations such as Oxfam and Consumers International are also listed. I think this probably gives us some legitimacy in claiming a reasonably representative constituency. So, allegations of poor representation dispelled. Let us then deal with the main complaint of Peter Martin’s response. He seems to believe that HAI is doing the bidding of governments who have a vested interest in restricting patients’ access to medicines. In other words there is an inherent conflict of interest in HAI accepting funding from European governments, to which I have two responses. Firstly, HAI is a global network and most of its work is conducted in developing countries through regional offices in Peru, Sri Lanka and Kenya. In those regions much of the fight is about increasing access to medicines, not limiting it. But it is about increasing access to essential drugs. So, he is right if he thinks HAI wants to rationalise access to medicines in developing countries – but only to those characterised by the WHO essential medicines list, access to which we want to promote. No drug rationing on behalf of European governments there, then. Secondly, the overwhelming majority of HAI’s funding comes from European governments’ overseas development agencies, not their ministries of health. This is a perfectly legitimate use of public funds, much of which is redistributed to our partners in the South and to date, HAI has won its funding in open competition from overseas development ministries in the Netherlands, UK, Finland, Sweden and Norway. Our interest in Europe stems from the fact that in a global market what happens in Europe affects what happens in the developing world. Our absolute opposition to the pharmaceutical manufacturers supplying information to patients is that it represents an absolute conflict of interest. Make no mistake - if the pharmaceutical industry are allowed to supply information to patients it will be advertising and will lead to irrational prescribing, increased medicine use (and therefore costs) and potentially increased morbidity and mortality. At least I can agree with Peter Martin on one point; HAI’s opinions probably are value-laden – HAI's values are that the interests of patients and consumers should come above the commercial interests of the pharmaceutical industry. I think that is defendable. Competing interests: Director, Health Action International |
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