*
Ai-
Deception by Design:
Pharmaceutical Promotion
in the Third World
Joel Lexchin
Consumers International Regional Office
for Asia and the Pacific, $15 + postage,
pp 91
ISBN 967 9973 68 9
eveloping countries are being
flooded with drugs, most of which
are useless, expensive, or dangerous.
All too often the pharmaceutical industry's
promotion of drugs leads to irrational
prescribing by doctors. Companies spend
about 20-30% of their sales budget on
promotion, providing free samples to doctors
to create demand for their products. In recent
years in many developing countries with
developing market economies, prices of medi-
cines have sometimes risen by 400-500%.
The main sources of information on new
and existing products are the drug companies,
either through mailings or visits by their sales
staff. Once doctors graduate from medical
school and set up in practice they are cut off
from the world of pharmacology. Only those
who are interested enough and find the time
will keep themselves abreast of the latest
developments in therapeutics-and these
form a very small minority. There is a strong
correlation between irrational prescribing and
use of commercial sources of information.
The information provided to doctors in
developing countries differs significantly from
that in developed countries. This double
A particular feature of Regional Anesthesia, edited by Marc B Hahn, Patrick M McQuillan, and George J
Sheplock (Mosby, ISBN 0 8151 4121 1), is its use of computer enhanced images to illustrate sites of
injections-in this case for lumbar sympathectomy. Illustrations of techniques are equally clear.
60
standard was highlighted by the US Office of
Technology. A panel convened by this office
examined prescribing information, package
inserts, printed matter provided to health pro-
fessionals, and samples of advertising for 85
products in Brazil and Panama. For 45 drugs
there was serious concern about the labelling
information.
Unfortunately the World Health Organisa-
tion's code on promotion of drugs has not
been implemented by most member countries
so it has made minimal impact on the
standard of promotion of drugs worldwide.
The International Federation of Pharma-
ceutical Manufacturers' code, which is
basically voluntary, is ineffective.
Interest in the promotional practices of the
pharmaceutical industry in the developing
countries has been increasing, and several
organisations are now working to increase
awareness and knowledge among doctors as
well as the regulatory agencies. Joel Lexchin
discusses the important issue of the export of
useless and dangerous drugs to developing
countries from the industrialised countries,
which are the main manufacturers of these
drugs. Out of a total of 3021 drugs, marketed
by the 20 largest European pharmaceutical
companies, only 482 (16%) were essential or
equivalent to an essential drug. Drugs banned
in one or more countries in the European
Union continue to be exported to developing
countries, in many cases by companies based
in the EU.
Lexchin gives suggestions for improving
drug promotion by banning irrational, use-
less, and dangerous products, controlling the
export of such drugs from developed
countries, strengthening and enforcing mar-
keting codes, and making doctors less
dependent on the companies for information
about drugs. I strongly recommend his well
referenced short book to doctors practising in
the developing countries as well as to health
authorities and even consumers. We must
curb unethical promotional practices in
developing countries so that the limited finan-
cial resources available for drugs may be used
judiciously and for the actual medical needs of
the population.-TARIQ IQBAL BHU'TA, profes-
sor of paediatrics, King Edward College and
Mayo Hospital, Lahore, Pakistan
Networks of Innovation:
Vaccine Development at
Merck, Sharp and Dohme,
and Mulford, 1895-1995
Louis Galambos, Jane Eliot Sewell
Cambridge University Press, ,C35, pp 273
ISBN 0 521 56308 9
F ear of plagues makes for bestselling
material. Books such as The Hot Zone
and The Coming Plague have made
bugs into Hollywood blockbusters. Networks
ofInvestigation chronicles a century of struggle
between industry and bacteria by telling the
story of Merck, Sharp and Dohme's efforts to
acquire, develop, and sustain the skills and
abilities needed to manufacture and market
new serum antitoxins and vaccines.
I had hoped for an entertaining and
insightful read. Insights there are, but this is a
book for aficionados of the topic: the style is
authoritative and complemented by exhaus-
tive footnotes concerning source material
(half the text on many pages).
Persevering with the text produced nuggets
of information. Jenner's seminal work on
smallpox, published in 1798 (after rejection
by the Royal Society), languished for almost
100 years awaiting the development of the
political, social, and industrial infrastructure
that could risk capital in the development of a
"new"2 type of medicine. There are parallels
with the advent of the biotechnology industry
in the 1980s and 1990s. An explosion in
scientific knowledge, passionate advocates
who can argue that this knowledge could
improve public health, and the development
of technologies that allow mass production of
the therapeutic substances are not enough.
Governments, clinicians, and the public also
need to be educated about the new
approaches and to be convinced of their ben-
efits before they will part with the money for
new products.
Merck's story presents a suitable frame-
work in which to explore the interrelations
between science and society that can make or
break a fledgling industry. It begins with the
BMJ voLuME 313 6 JuLY 1996
 EI
entrepreneurial activities of the Mulford
Company in the 1890s, when Mulford and
Campbell saw the promise in a diphtheria
antitoxin and-perhaps more importantly-
heard the public clamour for action. They
hired the appropriate technical experts and
became an industry leader in the development
and sale of vaccines and antitoxins within 20
years. But the creative energy began to wane,
and the company was acquired by Sharp and
Dohme in the 1920s. Economic calamity in
the shape of the depression and a failure of
vision muted the potential of this merger.
Opportunities such as the government-
subsidised influenza vaccine programme were
lost, and the company marked time until it
merged with Merck to form Merck, Sharp
and Dohme in 1953.
The new company had the resources to
build and maintain inhouse research and
development skills and was thus able to
exploit new technological and scientific
breakthroughs as they emerged (for example,
polysaccharide capsular vaccines in the 1970s
and recombinant DNA technologies in the Described as "an imaginative educational pro-
1980s). The scope and direction of Merck's gram," the two volumes of Cutaneous Medicine and
vaccine programmes was reviewed and Surgery, edited by Kenneth A Arndt et al (Saunders,
rereviewed, culminating in the establishment £184, ISBN 0 7216 4852 5), aim to present an
of the vaccine division-just in time to enter integrated, multidisciplinary account of every aspect
of the skin, its function, and its disorders. The illus-
the swells of American health care reform in tration shows the Australian box jellyfish, the sting
the 1990s. of which is the most dangerous of all, from a chapter
The story is an interesting one for those called "Aquatic dermatology."
who can fight through the footnotes. It holds
many valuable lessons for entrepreneurs and
shows that public clamour has been and
remains a critical factor shaping the health
care industry.-GARETH W ROBERTS, group to the disease process, but it would be
director, molecular neuropathology research, interesting to have an up to date comprehen-
SmithKline Beecham Pharmaceuticals, Harlow, sive explanation of the most recently
Essex described immunopathogenetic mechanisms:
autoantibodies, cytokines, adhesion mol-
ecules, apoptosis etc.
Treatment is extensively covered in all
chapters, those on the vasculitides being
particularly useful in their discussion of
Connecdve Tissue Diseases different therapeutic approaches. A chapter
on "therapeutics of the future" outlines the
most promising developments.
Ed Jill J F Belch, R B Zurier Paediatric rheumatology is also included,
Chapman and Hall, £79, pp 392 in a chapter that covers most of the connective
ISBN 0 412 48620 2 tissue diseases seen in children. It is important
to detail the outcome and long term implica-
rHt t ow can connective tissue diseases be tions of disease and treatment in children and
characterised? Most doctors con- this chapter answers such questions as fully as
sider the hallmark to be the presence possible.
of immunological changes in patients with The very long term outcome of diseases
systemic symptoms and multivisceral involve- and the effect of disease and treatments on
ment. Connective Tissue Diseases covers most quality of life are rarely considered in medical
of this heterogeneous group of disorders, texts. Such an important element should be
although it omits rare diseases such as relaps- included in subsequent editions of this excel-
ing polychondritis or hypereosinophilic syn- lent book.-L GUIu.EviN, professor of internal
drome, in which immune mechanisms remain medicine, H6pital Avicenne, Bobigny, France
unclear.
The book's target readership is physicians
and rheumatologists, but it would also be
valuable to students, trainees, and specialists To order books reviewed here contact the BMJ
interested in the subject. The chapters Bookshop, PO Box 295, London WC1H 9JR.
describe clinical manifestations, outcome, and Tel 0171 383 6244. Fax 0171 383 6662. You can
pay by cheque in sterling drawn on a UK bank or
treatment. Pathogenesis and immunological credit card (Mastercard, Visa, American
mechanisms are described only with reference Express).

BMJ VOLUME 313 6JuLY 1996