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Transcript of Ethics, Drugs and the Developing World: What Should We Expect of the Pharmaceutical Industry? Joel...
Ethics, Drugs and the Developing World: What Should We Expect of the Pharmaceutical Industry?
Joel Lexchin MD
School of Health Policy & Management
York University
Emergency Department
University Health Network
Why Are Drug Companies in Developing Countries?
“I would just be talking rubbish if Iwere to say that the multinationalcompanies were operating in the lessdeveloped countries primarily for thewelfare of those countries . . . They arenot bishops, they are businessmen.”
Spokesperson for the British
pharmaceutical industry
Outline
The ethics of clinical trials in developing countries Examples from Nigeria, Latin America
Provision of existing drugs - eflornithine The research agenda Promotion of drugs Intellectual property rights and drug prices Exporting of pharmaceuticals to developing
countries
Growing Research in the Developing World
Increase in no. of clinical trials 1995 - 2000 versus 1990 - 1995
Clinical Trials in Developing Countries
Current estimate is 18,000 - 24,000 trials in low
and middle income countries per year
SOMO. Ethics for drug testing in low and middle income countries:
considerations for European Market Authorisation. February 2008
Why Are More Trials Being Done in Developing Countries?
Larger pool of sick people Less red tape & oversight People sign up faster because of lack of
alternatives Use of placebos--easier to show treatment
effect Research personnel are paid less
RESEARCH IS 10-40% LESS EXPENSIVE
Ethical Approval - Developing & Developed Countries
Percent of respondents
Developing countries
Developed countries
Ethics committee in institution
58.9 94
Review body in institution
41.4 75
Contemporary Clinical Trials 2007;28:677-83
Differences Between IRBs in Developing Countries and US
Option Raised by developing country IRB
Raised by US IRB
Need for local language consent form
72/124 (58%) 27/32 (84%)
Need for letters of approval from developing country representatives
53/114 (47%) 26/33 (79%)
Confidentiality protections for participants not adequate
22/121 (18%) 13/31 (42%)
On 10 other items no differences between IRBs in developingcountries and US - J Med Ethics 2004;30:68-72
Pfizer, Trovan, Meningitis and Nigeria
The Body Hunters: As Drug Testing Spreads, Profits and Lives Hang in Balance
Washington Post, Dec. 17, 2000
Pfizer, Trovan, Meningitis and Nigeria
Study planned in 6 weeks versus expected 1 year in USA
Drug never tested before on children Oral form used Usual treatment in USA is intravenous
drugs Company has no signed consent forms
Surfaxin and Latin America Discovery Laboratories, Doylestown PA Synthetic surfactant (Surfaxin) 4 surfactants already on market (first in
1990) Associated with 34% relative reduction
in neonatal mortality “Without doubt the most thoroughly studied
new therapy in neonatal care” (NEJM)
Surfaxin and Latin America “Further placebo controlled trials of synthetic
surfactant are no longer warranted” (Cochrane Collaboration)
FDA: “Conduct of a placebo controlled surfactant trial for premature infants with RDS is considered unethical in the USA”
European trial: Surfaxin vs. approved surfactant
Surfaxin and Latin America Proposed locations for study: Mexico,
Peru, Bolivia, Ecuador Design: Surfaxin vs placebo (vs
approved surfactant in some settings)
Trials of Natural and Synthetic Surfactant: 1985-2000
0
1
2
3
4
5
6
7
8
9
19851986
19871988
19891990
19911992
19931994
19951996
19971998
19992000
No. of trials vsanother surfactantNo. of placebo trials
After 1992 only 2 trials against placebo
Other Trials with Ethical Problems
Organizations involved range from local companies to large multinationals
Provision of Existing Drugs - Eflornithine
First developed in France in 1970s by Merrell 1979 usefulness in treating African sleeping sickness
recognized Only other drug available melarsoprol - caustic arsenical - kills
5% of those who receive it About 500,000 infected annually Subsequently tested by subsidiary of Aventis for use as
cancer agent but results negative 1999 production discontinued
Then found to be effective depilatory for women in topical form (Vaniqa) & marketing started by Bristol-Myers Squibb
BMS & MSF reached agreement to supply drug for sleeping sickness
Drugs for Neglected Diseases 1975-2004
•1556 NCEs introduced•21 for neglected diseases
Lancet 2006;367:1560-1
Present Research Priorities in the Third World
20 of the world’s top pharmaceutical companies surveyed in 2001 about research in five diseases: sleeping sickness, leishmaniasis, Chagas disease, malaria, tuberculosis
11 complete responses: 8 companies spent nothing on sleeping sickness,
leishmaniasis, Chagas disease 7 companies spent less than 1% of total R&D
budget on any of the five diseases
The Model is Wrong"You can't expect for-profit organisation to dothis [produce new drugs for developingcountries] on a large scale. If you want toestablish a system where companiessystematically invest in this kind of area, youneed a different system.”
Daniel VasellaCEO Novartis
IFPMA Code of Pharmaceutical Marketing Practices
Self-Regulation of Pharmaceutical Promotion:
The international pharmaceutical industry is
committed to the improvement of the health of
mankind through research and development of new
medicines and the production and marketing of
pharmaceutical products of reliable quality, in
accordance with internationally defined standards of
good practice
Code of Marketing Practices Introduced 1981, most recent revision 2006 At same time WHO had just passed
International Code of Marketing of Breastmilk Substitutes & talk of doing same for pharmaceuticals
Harry Schwartz (defender of industry):Code an attempt to repel “a coming WHO effort to impose unacceptable controls over all pharmaceutical commerce in the Third World”
IFPMA View of Advertising
IFPMA Web Site:
“Advertising and promotions are an
essential means of alerting prescribers of
the availability and use of new drugs and
new uses for existing medicines”
Promotional Material Collected by a Malaysian GP in One Month
6 updates on drugs or treatments, 10 pens, 9notebooks, 24 brochures, 2 clinicalmanuals, 1 plush toy, multiple packs of twodifferent drugs, 3 articles, 4 plastic folders, 5 event sponsorships and dinners, 5 small gifts,1 screening program
Contents of Ads in Medical Journal in Developing and Developed Countries
Type ofinformation
Percent of ads containinginformation
Developedcountries
Developingcountries
Indications 89 87
Contraindications 61 28
Warnings 55 29
Side effects 64 29
Herxheimer. International Journal of Health Services 1993;23:161-72.
Analysis of Ads to Thai Doctors, 2003
Percent of ads with information
(n = 207)
Brand name
Generic name
ADR information
Cautions References for claims
100 90 23 25 52
36/207 ads judged to provide balance of information38/207 ads misleading
Kiatying-Angsulee et al. Presentation at Second International Conference on Improving Use of Medications, Thailand, 2004
Comparison of Information in United States and Brazil Drug Compendia - 44
Top Selling Drugs in BrazilCriteria Percent of times criteria missing
United States(PDR)
Brazil(DEF)
Adverse effects 5.6 57.2
Interactions 38.8 41.7
Indications 2.3 13.8
Contraindications 8.3 30.5
Overdose 11.1 38.8
Mechanism action 13.8 55.5
Pharmacologiceffect
5.5 41.6
de Barros. Pharmacoepidemiology & Drug Safety 2000;9:281-7
IFPMA Code
“It is understood that national laws and
regulations usually dictate the format andcontent of the product informationcommunicated on labelling, packaging,leaflets, data sheets and in all promotionalmaterial. Promotion should not be inconsistent
with locally approved product information”
Self-Regulation
“IPFMA will continue to supportself-regulation as the mostappropriate mechanism forregulating marketing andpromotional practices bycompanies”
Intellectual Property Rights (Patents)
Jonas Salk discoverer of Polio vaccine"There is no patent. Can you patent the sun?"
IFPMA & Intellectual Property Rights
“Strong patent and other
intellectual property rights are
vital incentives and protection for
innovation, especially in the
pharmaceutical sector”
International Prices - AIDS Drugs (Circa 1999)
Drug
USA Zimbabwe Tanzania Uganda
Zidovudine $1.69 $0.91 $2.29 $1.26
Didanosine $1.82 $1.34 $1.89 $1.31
Zalcitabine $1.88 $2.00 Ñ Ñ
Stavudine $4.56 $4.85 $5.07 $3.15
Lamivudine $4.33 $3.52 Ñ $2.74
Nevirapine $4.25 $5.18 $3.44 $4.72
TRIPS Agreement & Patents 20 years protection from time patent
filed However, provisions in TRIPS for
compulsory licensing Ability to produce drug by other companies
while product still protected by patent
IFPMA on Compulsory Licensing
“Compulsory licensing benefits nobodyexcept the fortunate commercial entity that is thebeneficiary of the largesse offered by such licenses.In the medium and long-term, it is patients who willlack new treatments for serious diseases that suffer,as researchers will undoubtedly stay away fromtargeted disease groups subject to CL policies”
Harvey Bale, Director General IFPMAApril 1999
U.K. Commission on Intellectual Property Rights
“Higher IP standards should not be
pressed on developing countries without
a serious and objective assessment of
their development impact”
IFPMA Response to CIPR
“Most importantly, the report fails
to underline the real needs of
developing countries to have
strong intellectual property
protection”
Canadian Efforts to Promote Generic Exports to Developing Countries
September 2003 Canada announced initiative to allow
Canadian generic companies to export to developing countries
Response from Harvey Bale, head of IFPMA: “It won’t solve a thing . . . [It will be a] negative black eye for Canada [that will] very well affect the investment climate”
Start ARTs: d4T/3TC/NVP
Substitute for toxicity:
TDF/FTC+EFV
Switch after failure: ABC+ddI+LPV/r
US$140/y
LDCs
US$ 1,700/y
x5
x2.5
x12
US$689/y
Middle-income
US$365/y
US$ 5,200/y
x3
x4
x14
US$ 1,175/y
Bullying Developing Countries 1999
39 companies launch lawsuit against South Africa arguing that new medicines law is unconstitutional because it allows for compulsory licensing
2006 Novartis challenging Indian patent law that
prevents patenting of trivial improvements of known molecules
Claimed not consistent with TRIPS
German Drug Exports to Developing Countries
67
33
61
39
5347
42
58
39
61
0
10
20
30
40
50
60
70
1984/85 1988 1991/92 1997/98 2003
Percent irrationalPercent rational
1321 drugs 1310 drugs 1417 drugs 2179 drugs
German drugs: poor choices for poor countries. BUKO Pharma-Kampagne, 2004.
2534 drugs
Some Examples Aspirin (Bayer)
Germany: “Not for use in children under the age of 12” (risk of Reye’s syndrome - often fatal liver disease)
Brazil: Specifically promoted for children Lesterol (Aventis)
Withdrawn in USA in 1995, in Germany in 1998 Continued to be sold in Brazil until May 2004
Dipyrone (Boehringer Ingelheim) Not sold in Canada, Sweden, UK, USA Marketed in Brazil, Central America, Mexico, Pakistan,
South Africa
Irrational, Non-essential or Hazardous Drugs, India 2005 Rank Brand name Producer Headquarters
1 Becosules Pfizer United States
3 Corex Pfizer United States
9 Liv-52 Himalaya India
11 Dexorange Franco-Indian India/France
12 Digene Abbott United States
17 Combiflam Aventis France
20 Polybion E Merck Germany
21 Glucon-D Heinz United States
22 Evion E Merck Germany
25 Revital Ranbaxy India
Consumers International. Drugs, doctors and dinners: how drug companies influencehealth in the developing world. 2007
What Should We Expect?
Just what we get!
The primary obligation of pharmaceutical
companies is to their shareholders NOT
to the people of the developing (or
developed) world
I hear a pharma justifying its actions on the grounds of Humanity, Altruism, Duty to Mankind, I want to vomit . . . It’s because I’m reading at the same time how the US pharma-giants are trying to extend the life of their patents so that they can preserve their monopoly and charge what they damn well like and use the State Dept to frighten the Third World out of manufacturing their own generic products at a fraction of the price of the branded version.
John LeCarréThe Constant Gardener