Adriano Cattaneo
The Royal Colleges, the British medical professional associations, receive a mountain of funds from the pharmaceutical industry. Between 2015 and 2022 they grossed over £9m. The lion’s share went to the Royal College of Physicians (2.8 million), and that of family doctors (2.4 million). Hard to think that this flow of money does not create conflicts of interest.
A series of articles published in March 2023 by the Lancet shows how commercial actors can negatively affect health.[1] The Lancet focuses especially on four enormous groups of commercial actors, those who produce and sell tobacco, alcohol, fossil fuels and ultra-processed foods, industrial products which together are responsible for 19 million deaths a year worldwide, equal to 34 % of total deaths and 41% of those from non-infectious diseases, according to the 2019 Global Burden of Disease data, considered underreported.[2] Commercial actors and their allies cause damage to health:
conditioning and directing political choices that strengthen commercial activities and simultaneously weaken control; bending science in their favor and sowing doubts on the results of scientific studies independent of commercial interests; implementing forms of marketing, increasingly digital, always more incisive and effective, however deceptive; by controlling and dominating the entire production and distribution chain, up to waste disposal; by managing human resources in such a way as to reduce their costs, with the diffusion of insecure, poorly paid, tiring and stressful situations; carrying out financial and reputation management activities that legitimize and give credibility to their every action; outsourcing all costs, including those for health and the environment, to the state and society.
These strategies were invented, field-tested and refined by Big Tobacco.[3] They were then adopted mutatis mutandisby all other commercial actors, especially by those conglomerates of transnational companies operating globally.
Big Pharma, understood as the ten or so companies that dominate the world drug market, but also including the companies that dominate national markets and those that control the medical device market, is no exception. Given the nature of the product, Big Pharma pays particular attention not only to relations with ministries of health and drug agencies, but also to relations with health professionals: doctors and their associations, academics and researchers, key opinion leaders. A book released a decade ago, originally titled Bad Pharma, details the mechanisms used by the industry to hook healthcare professionals and cheat users.[4] Among these mechanisms, payments of various kinds to professional associations, from congress sponsorships to project financing, including the development of guidelines, are of particular importance.
The literature on the subject is now exterminated. The latest investigations come from Great Britain. A first article concerns Big Pharma payments to Royal Colleges (RC)the denomination of many British professional associations introduced as early as the 16th century.[5] The majority of RCs’ revenue comes from membership fees, but surveys show that between 2015 and 2022 they received over £9m from many pharmaceutical and medical device industries. The lion’s share went to the oldest RC, the Royal College of Physicians (2.8 million), and that of family doctors (2.4 million). The author of the investigation asked the RCs to disclose the details of the sums received, but all, with the exception of the RC of anesthesiologists, legitimately refused, given that the law does not oblige them to be transparent on financial matters. The data published by the BMJ was downloaded from Disclosure UK, a voluntary database of the British federation of pharmaceutical industries which, as it is voluntary, may not report all payments and in any case does not contain details on the various types of payments and the projects or programs involved. which ones are intended. Figure 1 shows the payments to the various RCs by Big Pharma. Hard to think that this flow of money does not create conflicts of interest.
Figure 1. Big Pharma payments to various Royal Colleges
The RCs didn’t reveal how much money they had received, but some gave interesting answers:
“We are planning to make all payments public starting in 2023-24.”“We are not dependent on these payments, which amount to 1% of our budget.”“We only work with sponsors who share our goals.”“Le our internal procedures guarantee total independence from commercial interests.”“These funds allow us not to burden our members with certain costs.”“We work with some partners above all to make some events less expensive.”“We avoid payments that could undermine our reputation .”
Another article examines the characteristics of payments to professional and patient associations.[6] The authors compared firms based on the amount of money invested, the type of association targeted, and the type of payment. They also sought to identify differences in firm behavior across the 4 UK nations. Again the data comes from Disclosure UK. To address possible shortcomings of this voluntary registry, the researchers also carried out checks on the annual reports and websites of the relevant professional and patient associations.
The results concern 100 companies with payments to 4229 associations in 2015. In total, the payments totaled over £52m in England, £3.2m in Scotland, almost £2m in Wales and just over £500,000 in Northern Ireland. These figures appear to be proportional to the size of the 4 nations, but indexing by population size reveals a large difference in favor of England and against Northern Ireland, with Scotland and Wales in between. Pfizer was the largest donor anywhere, followed by Novartis and all the other firms. There were also numerous payments from many firms to the same small number of associations. On the other hand, some companies seem to favor payments in rain, ie not concentrated on a small group of associations. Often the payments were to organizations that plan and allocate health care, or that do research, such as universities. Many payments, however, were to individuals and associations that directly provide health care to the population. In each of the 4 British nations, firms prioritized different associations and different activities. In England and Wales, associations received smaller individual payments than in Scotland and Northern Ireland. Sponsorships of congresses and events were most frequent in Northern Ireland and least frequent in Wales. Approximately 5% of the total payments were incorrectly recorded when comparing Disclosure UK and Association records.
Meanwhile, a major firm like Novo Nordisk has been suspended by the British Association of Pharmaceutical Industries (ABPI).[7] An investigation by the Guardian on 12 March 2023 revealed that experts who had given a positive opinion to the National Institute for Health and Care Excellence (NICE) on a new slimming drug, semaglutide (trade name Wegovy), described in the article as “skinny -jab” (injection for weight loss), had received payments from Novo Nordisk.[8] Between 2019 and 2021, the firm had made over 3,500 payments, totaling £21.7m, to obesity charities, NHS trusts, RCs for event sponsorship, to general practitioners, health education providers and universities, as well as NICE consultants. Novo Nordisk had also helped fund a group of MPs lobbying in the area of obesity intervention strategies. Nothing suggests these payments broke any rules, and the firm says it has never “acted deliberately” outside ethical or legal standards. The recipients of the funding claim that they were unaffected by it and that they have adequately disclosed their conflicts of interest. Yet ABPI suspended Novo Nordisk; there will be a reason. And the reason is that, while remaining (almost always) within the limits of the law, Big Pharma anoints politicians, scientists and health professionals to promote its interests. It is up to us, informed health professionals, to be aware of this, to refuse payments and inform citizens, so that these economic pressures do not cause damage.
PS. On August 16, 2023, Kamran Abbasi, editor-in-chief of the BMJ, published an open letter in his magazine to the president of the RC Academy, Jeanette Dickson.[9] Based on Boytchev’s article,[5] he does not ask what it would be right to ask, namely that the RCs cut off their financial relations with Big Pharma, but only what we could define as the minimum wage: transparency. Will he get any response?
Adriano Cattaneo, epidemiologist, Trieste
https://www.thelancet.com/series/commercial-determinants-healthGlobal Burden of Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396:1204-22Brandt AM. Inventing conflicts of interest: a history of tobacco industry tactics. Am J Public Health 2012;102:63-71Goldacre B. Side effects. How drug companies deceive doctors and patients. Mondadori, 2013Boytchev H. Medical royal colleges receive millions from drug and medical devices companies. BMJ 2023;382:p1658Rickard E, Carmel E, Ozieranski P. Comparing pharmaceutical company payments in the four UK countries: a cross sectional and social network analysis. BMJ Open 2023;13:e061591Association of the British Pharmaceutical Industry (ABPI). Press release. Novo Nordisk is suspended from ABPI membership. 16 Mar 2023. https://www.abpi.org.uk/media/news/2023/march/novo-nordisk-is-suspended-from-abpi-membership/https://www.theguardian.com/business/2023/mar/12/revealed-experts-who-praised-new-skinny-jab-received-payments-from-drug-makerAbbasi K. Royal colleges must be more transparent on payments from industry. BMJ 2023;382:p1864 https://www.bmj.com/content/bmj/382/bmj.p1864.full.pdf
International Health Systems Big Pharma, BMJ, Conflict of Interest, Commercial Determinants of Health, Pharmaceutical Industry, National Institute for Health and Care Excellence (NICE), Novartis, Novo Nordisk, Pfizer, Royal College of Physicians, Royal Colleges, Ethical Standards o legal, transparency