Hard talk on association between public health advocates and pharmaceutical companies

By Bobby Ramakant
December 8, 2009
The author is a World Health Organization (WHO) Director-General’s WNTD Awardee (2008), writes extensively on health and development and manages the Stop-TB eForum. He is a Fellow of Citizen News Service (CNS) Writers’ Bureau.
Email: bobbyramakant@yahoo.com, website: www.citizen-news.org

Is it ethical for public health advocates to accept funding from pharmaceutical companies, or organizations directly/ indirectly affiliated to them? Should all direct/indirect engagement with Pharmaceutical companies should be declared openly and publicly? The delegates at the 40th Union World Conference on Lung Health in Cancun, Mexico, responded differently to this contentious issue.

The World Health Organization (WHO) and many other indexed publications ask people to sign a declaration form to declare any association with tobacco companies. The Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC, the global tobacco treaty) give teeth to the treaty which states, "in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law." The WHO FCTC Article 5.3 guidelines include the following recommendations, rooted in the principle that the tobacco industry has a fundamental and irreconcilable conflict with public health:
- governments should reject partnerships with the tobacco industry;
- conflicts of interest such as the "revolving door" between the tobacco industry and public health offices, government investments in the tobacco industry and tobacco industry representation on tobacco control bodies should be avoided;
- government interaction with the tobacco industry should be strictly limited and transparent;
- the tobacco industry should be required to be transparent about its activities, a measure which will help to counter interference by Big Tobacco's front groups and allied organizations.

Similar examples exist where people need to declare their association openly with formula food companies for instance. So is it ethical for public health advocates to take funding from pharmaceutical companies? Should it be declared openly?

When asked to respond to this question, Professor Hoosen Coovadia, noted paediatrician and expert in perinatal HIV transmission, former Head of the Department of Paediatrics at the University of Natal until 2000 and Victor Daitz Professor for HIV/AIDS research at the University of Natal, South Africa, said "unfortunately there is no simple yes or no answer to this. I guess in many instances that association [between pharmaceutical companies and public health advocates] has to be acknowledged and expressed fully. For example many of the good journals will not accept an article unless that association with food company, pharmaceutical company, depends what the company is, is openly acknowledged."

"People do believe in taking pharmaceutical companies' support in undertaking [clinical/ research] trials. It happens in National Institute of Health and many other institutions or these [public health] products will simply not have been tested. You can imagine a world where new drugs for TB and HIV are not available or not acceptable because those [clinical trials/ research] studies were not done" adds Professor Coovadia.

"There are some extreme examples on refusal to accept money [from companies]. One instance is taking money from tobacco companies because of their egregious behaviour of denying the damaging effects of tobacco. I am a paediatrician and we have been through decades of fighting formula food producing companies for the damage they do in developing world and probably in other parts of the world too in promoting their products in absence of support for exclusive breastfeeding for first six months. I think in those two instances public health advocates will take the position that any association with food company or tobacco company is inherently unacceptable" asserts Professor Coovadia.

"Any such association [between pharmaceutical companies and public health advocates] has to be declared openly. One of the examples is of one of the best drugs that we initially started off with to prevent mother to child transmission of HIV. It is a drug called nevirapine and we had the support from the manufacturers of nevirapine to do those studies. Now that is openly acknowledged, publications mention their association clearly, mention the role of drug company, and say in absolutely unambiguous terms that those companies have no influence on whatsoever in collection of the data, certainly not in the analysis of the data, or in the conclusions. In other words the scientific content of the paper or the article or the document was uninfluenced by that type of association. I think association with pharmaceutical companies can continue as long as those restrictions are adhered to" further adds Professor Coovadia.

"Pharmaceutical companies have enormous amounts of money that should be spent on research and development. It should be made mandatory for pharmaceutical companies to earmark funding for research and development, particularly in high burden countries" says Dr Darakshan Badar, Programme Manager, Provincial TB Control Programme (PTP), Punjab, Pakistan.

However, Dr Badar's colleague at the National TB Control Programme (NTP) in Pakistan, Dr Ejaz Qadeer, has a different opinion: "Public health advocates should not take money from pharmaceutical companies. There is an obvious conflict of interest and taking money from pharmaceutical company is risky for the [TB/ health] programme and also for the government. All association with pharmaceutical company of public health advocates should be open and [information regarding interaction should be] accessible to the public and other stakeholders to see what interaction is taking place between public health advocates and pharmaceutical companies."

"In Bangladesh, taking funds from pharmaceutical companies for TB is not common. Pharmaceutical companies are not willing to fund TB programmes because TB drugs are not available over-the-counter and given free to TB patients through DOTS" says Dr Zaman from Bangladesh.

"We can accept money from pharmaceutical companies to help TB patients but this should be open and publicly declared" says Dr Jean Pierre Kabuayi Nyengele, Deputy Manager, National TB Control Programme (NTP), Democratic Republic of Congo (DRC).

"The association between pharmaceutical companies and public health advocates should be openly declared" says Dr Peter Kimuu, TBCAP, Kenya.

"I don't think it is unethical to accept money from pharmaceutical companies. [However] the pharmaceutical companies shouldn't do unethical actions like promoting drugs or irrational use of drugs [after giving money]. It [association between pharmaceutical companies and public health advocates] should be declared openly and publicly, just like [we treat] tobacco companies" said Dr D Behera, Director, LRS Institute of Tuberculosis and Respiratory Diseases, New Delhi, India. Dr Behera was also awarded the Union Karel Styblo Public Health Award for this year 2009 at the 40th Union World Conference on Lung Health.

"For public health advocates, it is not ethically right to take money from pharmaceutical companies. All association between public health advocates and pharmaceutical companies should be open, and the agenda should be made public too" says Dr Razia Kaniz Fatima, M&E (Monitoring and Evaluation) ACSM Officer, NTP, Pakistan.

Well, there might be extreme difference of opinion on how ethical it is to engage with pharmaceutical companies and taking funding from them, but there is clear support to making this association open and public. Dr Coovadia's example of how manufacturers of nevirapine funded the research but had no control on scientific outcomes is worth remembering. The debate is certainly on, and more viewpoints and perspectives on this contentious issue be coming forth.

- Citizen News Service (CNS, www.citizen-news.org )

Posted on: December 08, 2009 11:34 AM IST