I recently received an invitation to attend a medical conference in another city. That, in itself, is nothing unusual. Conferences happen all the time, both within and outside Pakistan. What was unusual was that the invitation letter to the conference came packaged in an envelope along with a glossy brochure for a pharmaceutical company, advertising several of the company’s medicines.

It was perhaps 15 years ago while working in the United States that I was first introduced to the relationship between physicians and pharmaceutical companies (commonly referred to as ‘Pharma’). As with all trade relationships, this one is based on common interests. Pharma develops medications and medical interventions which in turn are used by physicians for treating all kinds of illnesses. It is, therefore, in the interests of both parties to maintain some kind of link. Physicians receive information about new medical interventions and Pharma develops new customers for its products through the physician community.

As with all relationships though, conflicts of interest and ethical pitfalls exist at multiple levels.

While in the US, I was invited to become a ‘promotional speaker’ for several pharmaceutical products. We would initially be taken to a medical conference organised by the pharmaceutical company (usually to a nice resort, all expenses paid). Over the weekend, we would be wined and dined and ‘taught’ about the new medicine, injection or whatever by renowned physician academics and researchers -- people from our field that we respected, presenting their research (usually sponsored by Pharma) on the effectiveness of the new medical intervention. There would be a session or two to train us on public speaking.

After we returned home, we would then be contacted by our local Pharma reps to talk to physicians and healthcare personnel. These talks would usually take place at local restaurants or hotels. We would be supplied with slides about the product, the audience would consist of physicians, nurses, sometimes hospital or clinic administrators and we would talk and answer questions for 1-2 hours about the product mixing pharma-supplied information and our own experience.

While the whole exercise was billed as ‘education’, it was, of course, a thinly veiled advertisement for pharma products delivered, not by pharma salespeople, but by physicians in an effort to enhance its credibility. For the 1-2 hour session we would be handsomely compensated.

I always had ethical reservations about these activities and many times contacted older physician friends and colleagues in an effort to get some guidance. Most of them would participate in these activities, so we consoled ourselves that we weren’t really doing anything wrong. Of course, the money helped assuage our guilty conscience.

Fast forward several years and I now lived and taught at a large public medical institution in Lahore. The year I returned, I was approached by several pharmaceutical companies about going to conferences, giving lectures etc. I always declined.

In the US, despite the shady nature of these activities, the law protected our patients and the public. All of us doing such promotional activities had to sign multiple legal agreements that specified what we could and couldn’t do or say. All these agreements specifically forbade us to write any specific medicine in exchange for any kind of monetary or other reward and also forbade us to ask others to do so. Pharma companies were very specific about this. Their legal departments gave us lengthy presentations on what we could not say to an audience. This was for their own protection.

While I was working in the US, several large pharma companies were heavily fined for violating these ethical standards (e.g. see here).

In Pakistan though, I soon discovered that ethical standards were lax and legal restrictions non-existent. There were stories of doctors being bribed with money, lavish overseas trips, cars, air-conditioners for their homes and offices and other less savory inducements. I decided early on that the best defense against this filth was to have no contact whatsoever with pharma.

The first year or two I was in Lahore, some adventurous pharma representatives tried to wink and get me to go along with an ‘educational talk’ or a ‘medical conference’ at a hill station. I mostly politely declined. One time though, after a particularly insistent gentleman told me that he had gotten the permission from my Head of department, thus insinuating that I had to attend his talk despite my objections, I lost my temper and almost physically threw him out of my office.

Needless to say, word has now gotten around and I am almost never approached by pharma reps for any activity whatsoever.

I still find it hard to believe that doctors in Pakistan refuse to see the terrible ethical conflict inherent in accepting favours and money from Pharma. And even worse is the low level of awareness among patients of how this can endanger their health and their lives.

Is a doctor prescribing you something because it’s what you need for your illness or because the company that makes it paid for his or her foreign trip? Are you being advised an operation or a medical device to improve your health or because the company bought the doctor a car or paid for their kids’ school tuition? Are you being prescribed expensive new medicines when a cheaper alternative would work because your doctor ‘owes’ the pharma company favours?

These are questions that all patients need to ask their doctors.

Sadly, healthcare ethics is still in its infancy in Pakistan. Most doctors learned in a system where taking bribes from pharma companies was perfectly okay. Their seniors did it and so they learned to do it too. Regulation and legal oversight are non-existent, opening the way to terrible violations of ethical standards bordering on criminal behaviour.

The few pharma personnel I have discussed this with are all in favour of reform. None of them feels good about bribing doctors or arranging illicit rendezvous in hotels for their prescribers. But, they say, that’s the cost of doing business. If they don’t do it, they will lose business and maybe their jobs.

The solution is simple: government needs to step in and regulate physician-pharma interaction perhaps through the newly empowered Healthcare Commission. Offending docs need to be censured and if they persist, their licenses to practice medicine should be suspended or revoked. Physician bodies need to get pro-active about monitoring their members and issuing warnings and censures to repeat offenders. And pharma needs to create a voluntary code of conduct that all pharma reps must abide by.

Human life is precious and those who take the oath to protect it must be held to the highest standards. Doctors and healthcare professionals hold great powers over us but "with great power comes great responsibility".