For Dr. Howard Brody, nearly three decades of family medical practice has afforded a clear view of the rising tide and spreading effects of drug industry marketing. As Brody entered the profession in 1977, that tide was coming in gradually. In the last decade, it has surged to account for at least $30 billion a year in spending.
Now 58, Brody sees a shift in the marketing tide. In recent years, politicians, consumers and physicians have begun to question sharply the effect of drug makers' commercial appeals. Medical societies and patients groups are quietly debating the wisdom of their dependence on drug companies' largesse. Doctors are rethinking, or at least disclosing, their ties to drug companies. Legislators are drafting and passing bills aimed at blunting the effects of prescription-drug marketing.
Along the way, Brody has evolved from family physician to medical ethicist. Now a professor of family medicine and director of the University of Texas' Institute for the Medical Humanities, Brody has been among those who have fomented a backlash. Sometimes, it's been a lonely journey.
For several years in his earliest days as a family physician in Michigan, Brody received a long line of drug representatives bearing gifts, jokes, an occasional journal article and, most important, the drug samples that, as he put it, "kept the cupboard well-stocked." The exchanges troubled him in ways that, as a young doctor in the late 1970s, he found difficult to put his finger on. But when he joined the medical faculty at Michigan State University and had the choice of opting out of such meetings, Brody did so with relief.
Two decades later, Brody read a commentary in the Journal of the American Medical Assn. that stirred up the same disquiet he remembered from his days meeting with drug reps. The 1997 JAMA editorial, "Thyroid Storm," told readers of a disputed study comparing thyroid medications. The study was conducted at UC San Francisco and was sponsored by Boots Pharmaceuticals Inc., a firm with strong commercial interests at stake. The study's findings came to a conclusion contrary to the sponsor's interests, and Boots threatened legal action if the study was published.
"The research community is getting progressively more entangled with industry, as became evident to me when I tried to find thyroid experts to review the paper who did not have financial ties" to Boots, wrote then-JAMA editor Dr. Drummond Rennie. The American Thyroid Assn. failed to rally to the researcher's aid in the dispute, leaving "the sad impression that the ability of the association to influence these events was weakened by its heavy dependence" on the drug maker's financial support, Rennie wrote.
In search of support
Brody found Rennie's account of the episode deeply shocking. But this time, his uneasiness found its voice. Starting in 2001, Brody began suggesting, at professional meetings and in conversations with fellow physicians, that the marketing of pharmaceuticals to doctors -- indeed the pervasive influence of drug makers within the medical profession -- had gone too far.
The response from colleagues was "very negative, very hostile," he recalls.
"It really sounded like, 'Who are you, sounding so scolding? You think you're better than us. How dare you?' " Brody said. "There had been this gradually creeping seduction going on all these years . . . and the pharmaceutical industry had happily supplied us with justifications for it. We doctors lapped them up eagerly."
But by 2004, those days were ending. The Annals of Family Medicine published an essay by Brody titled "The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives." (Brody went on to write a book, "Hooked: Ethics, the Medical Profession and the Pharmaceutical Industry," published this year.) Former New England Journal of Medicine editor Dr. Marcia Angell published "The Truth About the Drug Companies: How They Deceive Us and What to Do About It." Her fellow NEJM editor, Dr. Jerome Kassirer, continued the assault with "On the Take: How Medicine's Complicity With Big Business Can Endanger Your Health."
At a 2004 meeting of the American College of Rheumatology, physicians reeling from public outcry over the market withdrawal of the arthritis drugs Vioxx and Bextra vowed to wean their organization from its heavy dependence on pharmaceutical funding, setting off similar self-examination among other medical societies. While acknowledging that pharmaceutical sponsorship accounted for 34% of the group's income, its president at the time, Dr. David Wofsy, declared that the group's leaders, its young physicians, its political principles and its silence were "not for sale."
In statehouses across the country, meanwhile, lawmakers began to hammer out laws aimed at blunting the reach and the effect of drug makers' marketing efforts.
To date, at least 30 states have enacted laws, or have considered legislation, that would do so. Those include bills requiring the disclosure of gifts and payments by drug makers to physicians, limits on pharmaceutical companies' access to prescription information used for marketing purposes, advertising restrictions and limits on pharmaceutical sales representatives' gift-giving to doctors. California and Virginia have joined Vermont, Maine and Minnesota -- three states that have enacted the most sweeping laws on drug marketing -- in requiring reports disclosing drug makers' spending on advertising and marketing activities.
On Capitol Hill, a handful of lawmakers have launched hearings on the subject and suggest that legislation could come next. After presiding over a June 27 Senate hearing titled "Paid to Prescribe?," Sen. Herb Kohl (D-Wis.) suggested he would ask the prestigious Institute of Medicine to weigh in on the subject. He warned drug industry representatives to expect "progress" from a newly Democratic Congress.
The bid to curb drug industry marketing is hardly a juggernaut. Many of the state initiatives have been challenged as infringements on free-speech rights. Some have met resistance from physicians. Virtually all have been opposed by the drug industry, which, according to estimates by the Center for Public Integrity, has spent $758 million on lobbying -- more than any other industry -- since 1998.
Among rank-and-file doctors, Brody sees "almost a sea change" in attitudes toward drug marketing. For veteran physicians, the hostile defensiveness is no longer a reflex, he said. Among younger doctors and medical students, he sees genuine interest in reducing the influence of drug company marketing on the front lines of medicine.
Medical schools such as Stanford, University of Pennsylvania, Yale and, most recently, UC Davis and UCLA have sought to tighten rules governing relationships between physicians and drug makers, including a prohibition on the acceptance of even small gifts from drug reps. As of July, UCLA doctors can no longer accept or use pads, pens or gadgets emblazoned with drug company logos or images.
Many medical students also have organized to resist the commercial entreaties of drug makers. Since 2002, the American Medical Students Assn. has banned pharmaceutical advertising and sponsorships of national and regional meetings, as well as advertising on its website or in its magazine. The group's "PharmFree" campaign urges medical students to shun seminars and lunches sponsored by drug companies and skip the pad and pen giveaways.
The sea change Brody perceives appears to have come too late to head off the swelling wave of state initiatives and public calls for reform. Although doctors understandably resist the efforts of politicians to regulate the practice of medicine, Brody said they should have seen this coming. "The more we're seen as feeding on the largesse of the pharmaceutical industry, the less grounds the public has to have confidence in our putting their interests first, and the more they're going to try to step in and mandate reforms," Brody said. "I have to say, 'Gosh darnit, what did you expect, guys?' "