Intended for healthcare professionals

Rapid response to:


No more free lunches

BMJ 2003; 326 doi: (Published 29 May 2003) Cite this as: BMJ 2003;326:1155

Rapid Response:

The grip of the market

Dear Editor

Your theme issue on the drug industry and the “embrace of avarice and
excess” must serve as a mirror to see ourselves in.

The relationship between the pharmaceutical industry and the medical
profession is a natural one .As natural as that between the arms industry
and armies the world over. It can be one of constructive co-operation and
the health benefits are for all to see.
But it can be, as several robust studies and investigations have shown,
dishonourable and damaging.

So why do we indulge in such messy liaisons, full of biros, M&S
sandwiches, business class travel and lavish conference holidays? There
are the obvious reasons -pleasant sales persons, a sponsored break from
the drudgery of work and well, why not? The bigger factor is the global
and unflinching faith in the free market. Any debate on this influence of
marketing on decision-making and health outcome is considered too old
style and doctrinaire to be worthwhile. The rather subdued response to
your editorial 1and the issue in general from hospital practioners is a
testimony to what they think of it all. A waste of time. This mind set is
increasingly pervasive with students, junior doctors indoctrinated into
the free lunch way of life. The market has us all in its grip. The medical
profession, it appears will only see and believes what it chooses to.

Apart from the problem of potential influence in prescription, of the
devil quoting the scriptures to suit its purpose, there is the issue of
priority setting.

Decisions in cancer care, for example, are in the main, grounded in
evidence where it exists. Despite the army of reps set out to preach their
respective gospels, the existence of guidelines, protocols and consensus
statements make it difficult to influence the influential. There are
problems even here. So often the press will have stories of another cure
for cancer. The Health service is time and again accused of not providing
a “life saving drug” .The industry thrives on this publicity. Denying drug
treatment is a charge hard to bear, even for the rather stoic NHS.But
while there have been advances in cancer chemotherapy, the publicity and
promotion is often out of proportion to its real benefit. Surrogates of
outcome such as response rates, which even non-purists amongst us would
consider inadequate, may be quoted in an effort to create a niche for a
drug. The distortion of the agenda goes beyond this. Radiotherapy, an
important single modality of cancer treatment is considered just another
tool2. In comparison to other European and North American countries where
high quality radiation research and technology based studies are
encouraged, there are few departments in the UK that are able to retain a
commitment to this area of work. This is probably at least in part to the
lack of backing from an ambitious industry and the marketing that goes
with it. Achievements in radiotherapy, equivalent and often more
significant, hardly ever receive the fuss and attention that goes with a

Disentanglement is the key.The University of California in San Francisco
(UCSF) and the American Medical Student Association need to be commended
for their work..

It is crucial that that the U.K. moves in that direction starting with the
creation of blind trusts for education.. Apart from decanting the
influence of the brand, access to funds would be certainly fairer than it
is now. All health professionals, not just doctors, can than have access
to grants without having to court salesmen.

We are easily reassured by our own integrity. And I’m sure few of us doubt
the honour of our colleagues within the health system. But that is hardly
enough. Our increasing knowledge from this world of competition demands
that local codes and national ones such as those of the Association of the
British Pharmaceutical Industry (ABPI) are constantly scrutinised. The
industry-health service relationship needs re-configuring. The medical
profession so often challenges politicians on issues of conflict of
interest. The existing environment makes our position duplicitous and


1.Abbasi K,Smith R.No more free lunches bmj 2003;326:1155-6

2.Burnet et al Improving cancer outcomes through radiotherapy BMJ
2000;320 198-199
3.Saunders M et al Continuous hyperfractionated accelerated
radiotherapy(CHART) versus conventional radiotherapy in non small-cell
lung cancer:a randomised multi-centre trial.Lancet 1997;350:161-165

Competing interests:  
Free lunches.

Competing interests: No competing interests

25 June 2003
K. S. Madhavan
Senior Registrar
Radiation Oncology Department,St Lukes Hospital,Highfield Road,Rathgar Dublin 6