COMMENT: Banning medical drug reps from public hospitals —Dr Syed Mansoor Hussain - Monday, November 29, 2010

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As far as the public sector in Pakistan is concerned, the major arena for corruption occurs at the level of whatever ‘authority’ is responsible for buying medicines or devices in bulk for government-run hospitals and dispensaries

The Punjab government has banned the entry of medical representatives (reps) into public hospitals. Medical reps or drug company salesmen have always been a part of every medical establishment. In the hierarchy of people that work for pharmaceutical companies and suppliers of medical equipment, medical or drug reps are the foot soldiers of the industry.

“Big Pharma”, as it is often referred to in the US, has had a long and often corrupt relationship with providers of medical services, including hospitals and doctors. Recently stringent limitations have been placed on what ‘free’ supplies and inducements pharmaceutical companies can provide to physicians. But Pakistan is not the US.

For most of my life I have dealt with medical representatives, also known as ‘drug reps’. As a child I remember going to my father’s clinic at the end of his work day to pick him up. While I waited for him to finish, the last thing on his agenda was the visiting drug reps. They would show him the latest literature on new drugs they were selling and then leave a few drug ‘samples’ for him to try out on his patients. These samples often came in very handy to treat the very poor who could not afford even the cheapest medicines.

During my years in medical college many drug reps used to hang around the King Edward (KE) canteen. Some of them were originally medical students who took up this profession to support themselves till their suspension from medical studies was over. They had been suspended for varying number of years for involvement in student activism. Getting to know some of them made me quite sympathetic to the grunt work done by them while trying to make a living.

Coming back to the relationship between medical suppliers and the physician community, there is much collaboration, some collusion, and considerable corruption. Almost all important medical developments take place as a collaborative effort between doctors and medical entrepreneurs. In my own specialty of cardiac surgery, most artificial cardiac valves that we use are named after the physician that designed them and the engineer or engineering company that built them. So far so good.

Problems start arising when a new product moves out of the realm of the laboratory and has to be tried out on actual patients before it is approved for general human use. Here then a large number of physicians have to be recruited who are willing to try out a new product in what are called ‘controlled’ trials. This can lead to some form of inducements in the form of direct or indirect monetary benefit to those who are recruited to ‘study’ these products on actual patients. This might be called collusion of sorts but the end result is often beneficial as far as the new product and its usefulness for patients is concerned.

Things start getting sticky when the product has been approved for human use and now has to be marketed. Here the business mentality takes over and corruption steps in. Many inducements are then offered to physicians who can prescribe or use these products for patients or are in a position to recommend that hospitals that they are attached to should buy them often in bulk. In the US, as a result of the above problems, considerable efforts are being made make the relationships between physicians and medical suppliers as transparent as possible.

In Pakistan there are no drugs or devices being developed or going through trials for acceptance by any regulatory authority. All the efforts of the pharmaceutical industry are therefore focused on getting physicians to prescribe their medicines or use their devices on patients. Here considerable corruption does take place. Busy private practitioners are offered direct or indirect financial inducements to prescribe a particular medicine or use a particular device. The ‘cleanest’ of these inducements are probably offers of foreign trips to clinical conferences, all expenses paid, and a few dollars on the side for shopping. If nothing else, the physician might at least learn something useful.

As far as the public sector in Pakistan is concerned, the major arena for corruption occurs at the level of whatever ‘authority’ is responsible for buying medicines or devices in bulk for government-run hospitals and dispensaries. Billions of rupees are spent and therefore significant amounts of money are passed ‘under the table’ to those who are in a position to decide about what particular product to buy. This also often leads to the purchase of substandard products at inflated prices, or expensive alternatives when cheaper ones are equally useful.

One of the areas of physician ‘enticement’, especially at the junior level, is the medical education expenditure of most pharmaceutical companies. This includes two types of activities: first, subsidising medical conferences and seminars and second, paying for lunch and perhaps passing around a few free pens or key-chains after a medical presentation aimed at ‘educating’ medical trainees. And it is in these two areas, especially the latter, that most drug reps are involved when they visit ‘teaching’ hospitals. Providing information about drugs or devices that are already in use or have been recently introduced to young physicians is in my opinion definitely not a waste of anybody’s time.

What, however, is a real waste of time for most doctors in public hospitals is the interference in patient care by bureaucrats, politicians and other self-styled VIPs. Such people routinely send in patients for treatment. These patients are called ‘protocol’ patients and demand special treatment. This diverts meagre resources and physician attention from other patients. Worse, these protocol patients reinforce the idea in the minds of young physicians that sycophancy and catering to the whims and wishes of powerful people is the best way to get ahead in life.

Many things can and should be done to improve our public hospitals and minimise corruption during these difficult economic times. Banning the entry of medical reps is definitely not one of them.

The writer has practised and taught medicine in the US. He can be reached at

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