link to The Malta Independent
by Daphne Caruana Galizia
Pierre Mallia, a general practitioner and a specialist in bio-ethics, who is also a former president of the Malta College of Family Doctors, has said that it isn’t true that some doctors receive bribes to prescribe certain brands of medicines. In an interview with another newspaper, he described the accusation as “banal”, and said that in his 14 years in the field he had “never come across such a case.” Oh dear, oh dear. Dr Mallia is foolish to stick out his neck on behalf of every doctor in Malta. How can he vouch for their behaviour?
The problem of graft is all-pervasive in Malta, and nobody can claim that doctors are an exception. The door needs to be flung wide open on this matter, and not slammed shut with a pseudo-authoritative note of finality. Dr Mallia may be a good man and an ethical doctor who does not take bribes, but he is in no position to speak for others. If he believes that he is protecting the respectability of the medical profession, he is wrong. We would have more respect for doctors if those who are ethically correct were to get together and blow the whistle on the wrongdoers, difficult though that may be in a small place like Malta.
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The Chamber of Small and Medium Enterprises, better known as the GRTU, has suggested to the government that it should bar doctors from prescribing branded medicines, obliging them to prescribe generics instead. This would mean, for example, prescribing paracetamol rather than brand X of headache tablets.
Many generic medicines are exactly the same thing as those sold under a brand name, but they are much cheaper because brand-marketing and hefty research costs are not factored into the price.
The government has turned down the suggestion, because you cannot ban doctors from prescribing branded medicines – though you can make it illegal for them to accept gifts or hospitality from the pharmaceutical industry, or rent-free clinic rooms in pharmacies in exchange for a certain turnover in prescriptions. It was the GRTU’s proposed method of control, rather than its recognition of the need to control the situation, that was misguided. The GRTU’s members are attuned to what is happening, because they know the story from the inside: from suppliers of medicines and from those who retail them. They also know that the bribery and manipulation that takes place – despite what Dr Mallia has to say – are distorting the market in favour of very few brands, while other brands suffer from lack of sales. Patients suffer too, because they are being made to spend money unnecessarily, sometimes on medicines that can actually cause them harm. I had direct experience of this some time ago when a doctor at a health centre, where I had taken my youngest son who was in too much discomfort to sleep, prescribed a prominent brand of antibiotic. The next day, a Sunday, he broke out in a horrible vicious red and painful rash that covered his entire torso. We rushed him to the emergency department at St Luke’s Hospital, where the doctor in charge called the juniors for a look. “This is what happens to some people when you give them antibiotics and they have a viral infection,” he said. “It’s one of the reasons why no doctor should ever do it.” He was beside himself with annoyance, and I was furious that I had been made to pay money to cause my son such distress rather than cure him.
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Fortunately, our family doctor is an honest and reliable person, but I have had the occasional experience with others, including a couple of specialists, who prompted me to suspect that they were doing their best to drum up as much trade as possible for the pharmacy in which they held their clinic. The most recent of these experiences was a Lm40 bill when one of my sons, who had a run-of-the-mill throat infection for which the usual prescription is more rest and no late nights, paid a visit to a clinic in the absence of our usual doctor, and was given a costly blood test and some appallingly expensive pills. How ethical is it to carry out a Lm20 blood test on a 17-year-old who presents with an ordinary sore throat and a fever, when he is too inexperienced to question the doctor’s judgement and when he is clearly not the one who will be paying the bill? Heaven alone knows how they rip off people from a poor educational background, who don’t feel confident enough to ask questions.
So, I would have to ask Dr Mallia this: is drumming up business for the pharmacy that gives you free or cheap clinic space a form of bribery or corruption? I would say that it is. The patient-cum-customer can’t prove it. When challenged, the doctor will simply say that the Lm20 packet of pills was essential, or that the blood test was done to help the diagnosis.
Dr Mallia may be shocked at the suggestion that this happens. He may even call my accusation “banal” – but he can take it from me: it happens. It has happened for years and it is happening still. It will continue to happen until the government and the Medical Council jump on these people with bared fangs and talons. Then they might realise just how seriously irresponsible and corrupt their behaviour is. In doing this, the government will be helping its own public health endeavours. A couple of years ago, it tried to initiate a campaign to reduce the prescription and consumption of antibiotics because they are causing health and environmental problems and bacteria are becoming resistant to them. That campaign was doomed to failure because doctors are under tremendous pressure to prescribe two particular brands of antibiotic. Anybody who has raised small children in the past 20 years will know which these brands are. Even vets are prescribing them, for dogs. I used to hear from other mothers that they were even prescribed for what was plainly a virus: a streaming cold, say, or the usual feverishness. That happened to me once or twice, before I changed doctors, and when I asked the medical practitioner why he was prescribing an antibiotic when he had told me that the infection was viral and not bacterial, he brushed me off with the excuse that the child had better take the antibiotic “just in case”. What insanity – I crumpled up the prescription before I left the clinic.
The extreme pressure to prescribe these particular antibiotics is like a chain. The manufacturer puts pressure on the distribution agent to sell as much as possible, and the distribution agent, so as not to incur the manufacturer’s displeasure which might bring about the cancellation of the distribution agreement, looks for ever more enticing ways to persuade doctors to prescribe the brand. All of these ways are corrupt, unethical and illegal in civilised countries, except one: persuading the doctor that he or she should prescribe your product because it is cheaper and more efficacious than the competition. This is also the only permissible reason for doctors to prescribe a particular medicine for those who need it.
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Only two months ago, The Sunday Telegraph ran a report headlined Doctors who take drug firm ‘freebies’ face being struck off. This is not about money, commission or straightforward bribes, you understand, but about “freebies”: gifts, hospitality, the payment of flights and hotel accommodation for doctors and their “partners” who are invited to overseas conferences which are really just short holidays in disguise, and even seemingly “small” things such as a ticket to a concert. The news report described how the General Medical Council of Britain has revised its rules so that any doctor in Britain who is found to have accepted a present or any form of hospitality from a drug company will be struck off the register. The GMC has asked doctors to blow the whistle on colleagues whom they know to have accepted bribes like this.
The Sunday Telegraph report said: “The decision to toughen up the rules comes as evidence increases that, in return for promoting their products, some doctors are taking inappropriate gifts and hospitality from the pharmaceutical industry. Last month, a report by Consumers International, a campaign group, said that doctors were continuing to accept kickbacks, gifts, free samples and consulting agreements in exchange for prescribing or promoting drugs... In February it emerged that a senior manager at Abbott Laboratories, the drug company, had taken a hospital doctor to a lap dancing club. Abbott also admitted providing hospital consultants with Wimbledon tickets and taking 63 doctors to a greyhound race meeting in Manchester.” And Dr Mallia is foolish enough to claim that the very same does not happen in Malta, just because Sherlock Holmes has not come back with photographs of Dr X accepting bags of gold from Antibiotic Ltd.
The GMC’s spokesman on standards and ethics was quoted by The Sunday Telegraph as having said: “It is vital that patients can rely on the fact that doctors are prescribing them a drug in their best interests and not as a result of bribes or junkets that they’ve received.” Dr Richard Nicholson, the editor of the Bulletin of Medical Ethics, was quoted in the same report. “I’m afraid there is an awful lot of sleaze going on in the medical profession,” he said. “If doctors are at risk of being disciplined, or even struck off, they are more likely to think twice about accepting money or gifts.”
Dr Mallia and others who think as he does should get out more, and our Medical Council should align itself with its British counterpart and make doctors in Malta liable to be struck off the register for accepting free flights, goody-bags, and presents “for the wife” from those who want them to prescribe as many antibiotics and Lm30 packets of pills as possible. If this isn’t done sharpish, then we will really be living in a very sick country.