Laura Shea, R.N., Prevention First Coalition

Health care budgets... health care commissions... public health crises... rising rates of cancer... medical system breakdowns... medical breakthroughs. Rarely does a day go by without a report about some aspect of our health care system.

On April 9th, BCAM hosted a public information event, "Pills, Profits and Women's Health", that brought together 200 health care consumers to hear about, discuss and debate the pharmaceutical industry's influence on health care in Canada.¹ Our speakers were Barbara Mintzes, a researcher at the Centre of Health Services and Policy Research, University of British Columbia, and a leading expert on direct-to-consumer advertising (DTCA) and Claude St-Georges, a health policy specialist for the Confédération des syndicats nationaux and activist with Coalition Solidarité Santé, a strong critic of the Quebec government's current public/private drug plan. Nancy Guberman, professor of Social Work at UQAM and an active and dedicated BCAM member did a fabulous job of moderating the evening.

How The Hype Can Hurt
"Advertising: the science of arresting the human intelligence, long enough to get money from it." Stephen Leacock

Barbara Mintzes spoke first, explaining why — for good reason — every industrial country except the United States and New Zealand prohibits direct-to-consumer advertising (DTCA) of prescription drugs to consumers. Contrary to industry claims, prescription drug advertising is not educational. Like all advertisements, these drug ads aim to sell products and maximize profits. "The main claim presented as a justification for allowing prescription drug advertising," said Mintzes, "blurs the distinction between advertising and information. The fact is, a company runs an ad to stimulate sales; if the ads don't work, they will pull them and use another advertising strategy. Advertising is not a source of impartial objective information. The choice of what to advertise is a marketing decision, not a public health decision."

In 1990-1991 in the U. S., the pharmaceutical industry spent less than $100 million U. S. advertising prescription drugs. By 2002, this had increased to $2.7 billion U. S. Direct-to-consumer advertising (DTCA) works. The enormous investment in promotion directed at consumers clearly affects patient attitudes/behavior as well as doctors' prescribing practices. Mintzes' own study of the impact of DTCA on health care found that patients often request advertised drugs and doctors tend to prescribe them despite reservations about the appropriateness of the drug.² Moreover, consumer surveys demonstrate that when consumers ask for a drug they have seen advertised, they are likely to get it. Last year, over 8 million Americans went to their doctors, asked for an advertised drug and received a prescription for it.

Aside from the impact of DTCA on rising drug costs, Mintzes deplores the broader implications of drug ads that are carefully crafted to play on the public's fears of illness, aging and death. These ads often seize normal, natural life sitnuations as marketing opportunities and redefine them as medical events — a tendency that leads to the over-medicalization of everyday life.

Drug Advertising Is Costly to Canadians

• In Canada, drug companies spend more on marketing and promotion than on research and development.
• In 2000, drug companies spent an estimated $1.2 billion promoting their products to consumers and health care providers.
• In 2001, more health care money was spent on retail drugs than on physician services.
• Newer drugs are more heavily promoted and are typically more expensive, although they are often no better or safer than existing drugs.
• Despite reservations about the value of a drug, doctors tend to prescribe advertised drugs when patients request them.
• Roughly 70% of the Health Protection Branch's operating costs, once paid out of Canadian tax revenues, are now derived from industry user fees, potentially creating conflicts of interest.
• As a public health measure, all developed countries except the U. S.A. and New Zealand ban advertising of prescription drugs directly to consumers.

Sources: British Medical Journal, Canadian Medical Association Journal, Canadian Institute for Health Information, IMS Health (Canada), Women and Health Protection Marketing pills to healthy people

In their desire to expand the market for their products, pharmaceutical companies target healthy persons by exaggerating the risks of a condition or disease and advertising drugs to counteract them. As Mintzes noted, "The creation of diseases exists in tandem with the production of drugs. Should healthy people be convinced that they are ill?"

The advertising of tamoxifen is an example of how drugs that are approved for one use are then advertised for another. Tamoxifen, a drug approved in both Canada and the U. S. for the treatment of hormone-dependent breast tumours, has also been approved (in the U. S. only) for the temporary risk reduction of breast cancer. It is not approved as a preventative. Using carefully crafted ads, the manufacturer has positioned tamoxifen as a way of preventing breast cancer, despite the fact that it is not intended to be used this way. "This is a drug that is useful in its place," according to Mintzes, "but not something that a healthy person would necessarily take. There are severe risks associated with its use."

Thus far, cancer research has been focused on drugs because that's where the profits are. However, advertising any drug for cancer prevention presents problems because all drugs have side effects and/or long-term effects. What often occurs is 'disease substitution' where a drug that reduces the risk of one health problem actually increases the risk of another. True prevention requires serious commitments from government, at all levels, to reduce the public's exposure to cancer-causing chemicals and radiation.

At one time, Health Canada was willing to publicly support the ban on DTCA, agreeing that it was needed to minimize risks associated with the inappropriate use of prescription drugs. Today, that sort of support is hard to come by. In cities across Canada, one can find billboards promoting "Diane-35" to treat acne, as well as print and TV ads promoting "Viagra" for male sexual dysfunction. As Mintzes points out, "Not only are we exposed to more and more made-in-Canada ads but, ever since the U. S. relaxed its regulations on broadcast advertising, we have a lot more exposure to DTCA from American media."

Mintzes is part of Women and Health Protection (Canada), a group fighting to have the existing ban on DTCA strengthened and enforced. At the same time, a coalition of pharmaceutical company representatives and media personnel has been lobbying to have the ban lifted. So far, it's a standoff, with Health Canada at a standstill. "In Canada", said Mintzes, "a so-called patient group entirely financed by the pharmaceutical industry was founded solely to lobby for the legalization of DTCA."³

Claude St-Georges spoke on behalf of La Coalition Solidarité Santé, a coalition of 45 organizations working together since 1992 to preserve a fully public, universal health care system, accessible to all. Their efforts have also included advocating for equal access to affordable medications for all Quebecers at a time when the rising cost of drugs has made them prohibitive for many.

St-Georges warned about ... "the dubious practices of some brand-name drug manufacturers that, in themselves, constitute a public health problem." St-Georges was also concerned about prescription drugs promoted to consumers and physicians, adding that this kind of promotion contributes to unacceptable increases in drug costs. A further problem stems from the fact that most doctors get information about the drugs they prescribe from the drug company representatives. He cited a recent documentary on Radio Canada's "Enjeux" that revealed that the manufacturers invest over $20,000 per doctor to familiarize them with their products.

There are additional concerns about the relationships between governments, federal and provincial, and the pharmaceutical companies. Because pharmaceutical companies contribute substantially to political party coffers, the public is left to wonder just where the government's best interests lie. In Quebec, drug patent protection can be extended by five years longer than in the rest of Canada, an extension which is costly to Quebecers.

But St-Georges did not let the generic drug companies off the hook. He pointed out that generic drug companies tend to inflate their prices once their drugs are on the market. Just this year, investigative journalismrevealed that generic drug companies in Quebec were paying pharmacies to sell their products.

St-Georges blames the current public/private system for the soaring costs of medicating Quebecers which has increased from $1 billion to $2.2 billion in six short years. As the prices rise, more and more of the cost is shifted onto the users and is "ultimately a threat to public health care."

Quebec's Drug Plan: Some facts

• Drug costs are the most inflationary part of the Quebec health and social services sector.
• Some private insurance companies have increased their health insurance premiums by more than 40% in two years.
• A majority of interested parties, excluding private insurance companies, opted for a fully public plan during public consultations on the medication insurance program.
• The after-tax profits of pharmaceutical companies was 40.9% for the period 1991 to 2000 — as compared to the 10.7% profit rate that banks received on credit cards.
• A reliable report calculates that the current drug plan has created a situation where 13,000 people made avoidable visits to the Emergency Room and triggered more than 4,000 "adverse events" linked to a decrease in the use of medication.

Sources: La Coalition Solidarité Santé, "Electoral guide for citizen involvement during the 2003 Québec election campaign". Press release March 26, 1999: "Evaluation of the Impact of the Quebec Drug Insurance Plan": www.muhc.mcgill.ca/Releases/p260399.html

Where do we go from here?
In closing, Claude St-Georges exhorted his listeners to insist that our governments maintain the public nature of health care, with universal and free access to the system. He cautioned his audience not to subscribe to the view of the world as one vast market to liberalize, privatize and deregulate. "Having access to medicine is just a important as having access to doctors," said St. Georges, "and a universal, fully public drug plan is the only way to ensure it."

Ending with a cautionary tale, Barbara Mintzes argued that "... medicine needs to revert to its traditional, useful place as a treatment option based on sound, evidence-based science." It was recently revealed that menopausal hormone replacement therapy can cause more harm than good (see News Briefs) — an excellent example of the triumph of marketing over science. Rather than spending money on advertising their prescription products, pharmaceutical manufacturers should be developing and distributing medications to counter serious illnesses and/or life-threatening diseases like malaria and AIDS.

To register your protest about the advertising of prescription drugs to consumers, contact:

Honourable Minister Anne McLellan
Minister's Office - Health Canada
Brooke Claxton Bldg., Tunney's Pasture
P. L. 0906C
Ottawa, ON K1A 0K9
Email: Minister_Ministre@hc-sc.gc.ca OR mclela@parl.gc.ca

Ann Sztuke-Fournier
Manager, Advertising and Risk Communications Section
Marketed Health Products Directorate
Address Locator: O2O1D1
Tunney's Pasture
Ottawa ON K1A 0K9
Email: Ann_Sztuke-Fournier@hc-sc.gc.ca

BCAM extends its heartfelt thanks to the Prevention First Coalition and CKUT (Radio McGill) for supporting the event, and to all those who endorsed the event, helping to bring this important issue to the public's attention: Canadian Women's Health Network, Centre for Research & Teaching on Women (McGill University), DES Action Canada, Institute in Management and Community Development (Concordia University), La fédération de femmes de Québec, NDG Coalition for Health Care, Physicians for Social Justice, Project Genesis, Quebec Public Interest Research Group (QPIRG Concordia University), Quebec Public Interest Research Group (QPIRG McGIll University), Regroupement intersectoriel des organismes communautaires de Montréal (RIOCM), Relais-Femmes de Montréal, Simone de Beauvoir Institute (Concordia University), South Asian Women's Community Centre, The Urban Ecology Centre, and the Y. W.C. A. Our thanks also to Joan McCordick and Taous Selhi, simultaneous interpreters, who donated their expertise, to Leslie Amy of L. M.B. Interpretation System Services for providing the technical equipment, and to the kind partners of Copie Resolutions who printed up additional copies of the BCAM History.

Footnotes:

1. Website resources: Canadian Women's Health Network, Centre for Health Services and Policy Research, U.B.C.: La Revue Prescrire, National Institute of Health Care Management (NIHCM), Women and Health Protection
2. Mintzes B, Barer ML, Kravitz RL, Kazanjian A, Bassett K, Lexchin J, et al. Influence of direct to consumer pharmaceutical advertising and patients' requests on prescribing decisions: two site cross-sectional survey. British Medical Journal 2002; 324: 278-279
3. In order to remain independent from industry influence, BCAM adopted a Policy on Corporate Contributions in March of 2001. BCAM will not knowingly accept funding from pharmaceutical companies, chemical manufacturers, biotech and agri-business, oil companies, tobacco companies, private cancer diagnosis and treatment facilities, or companies that develop and market cancer-related technology