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Multinational pharmaceutical companies are lavishing doctors in the world’s poorest countries with cash, extravagant meals, expensive gifts and even livestock as incentives to write prescriptions for their drugs, according to a report issued recently by Consumers International, a London-based nongovernmental organization of consumer-rights groups.

The report, titled “Drugs, Doctors, Dinners,” accuses a drug industry desperate to allay falling profits in mature Western markets of using bribes in order to sway the prescription habits of doctors in the developing world. In nations like Pakistan, India, Malaysia, Sri Lanka and China the drug makers ply doctors with air conditioners, laptop computers, club memberships, domestic cattle, all-expenses-paid trips to conferences at five-star hotels in foreign nations, new cars, and even paid college tuition for the physician’s children, according to the report. In exchange, these doctors promise to prescribe expensive, brand-name drugs, thereby boosting the pharmaceutical companies’ profits – but also risking the health of their patients and costing them money they don’t have.

“The pharmaceutical industry sees the developing world as a trillion-dollar opportunity to secure profits over the next forty years,” Richard Lloyd, Consumers International director general, said. “Weak regulation makes these markets an easy target for the marketing techniques of multinational drug companies, but consumer health expenditures in these countries can ill-afford to be squandered on irrational drug use."

Established in 1960 as the International Organization of Consumers Unions by national consumer-advocacy groups, Consumers International has evolved into a federation of 230 member organizations in 115 countries. It is represented in the United States by prominent watchdog groups such as the Consumer Federation of America, Consumers Union Inc. and the American Federation of State, County and Municipal Employees.

Luke Upchurch, Consumers International media director and co-author of the report, said the drug companies are stepping up their marketing efforts in countries like India because they see them as new and potentially very lucrative sources of revenue at a time when Western markets like the United States are maturing.

"As profits begin to slow in the West, the pharmaceutical companies are beginning to look at emerging economies as new opportunities to increase their profit margins," he said. "Emerging markets have money like never before, and this is particularly true in Southeast Asia, which is home to a burgeoning middle class. The drug companies are very aware of this."

He cited ongoing efforts by the international pharmaceutical industry to boost sales in poor countries of so-called "blockbuster" drugs, or those that generate more than $1 billion in revenue annually, which are typically used to treat Western ailments like obesity and mental illness.

"Obesity is a problem that is expanding worldwide, and that includes the developing world," Upchurch said. "But there are more pressing issues in these countries that the pharmaceutical companies should be focusing on, like malaria, cholera and dysentery. Consumers International advocates increased drug marketing on priority drugs for contagious diseases and preventative health measures."

But that may be a tough sell, as the rate of inappropriately prescribed medicines has soared in many poor nations, according to several recent studies. In 2005, the Indian National Commission on Macroeconomics and Health labeled 10 out of 25 top-selling brands of medicines in the country as being either “irrational or non-essential or hazardous.” Those brands included blockbuster drugs manufactured by American pharmaceutical giant Pfizer Inc.; Himalaya Drug Co., a Bangalore, India-based manufacturer of herbal and Ayurvedic medicines; German drug maker Merck & Co. and Ranbaxy Laboratories Ltd., the Indian generic drug giant.

Separately, the British government’s Department for International Development estimated in a January 2006 report that nearly half of all medicines dispensed in developing nations are prescribed inappropriately, and half of the patients who receive these medicines use them improperly. The study also criticized the pharmaceutical industry for its marketing tactics, which it says have compounded this problem by misleading the public and patients. It concluded that poor people in developing countries often receive little health benefits for their prescription-drug expenditures.

"This is a major problem, and the correlation that we tried to draw in the report is the relationship between the amount of money and time spent by the pharmaceutical companies in poor countries," Upchurch said. To illustrate this point, Consumers International persuaded Dr. Rafik Ibrahim – an experienced general practitioner in Malaysia's Klang Valley region – to track all of his interactions with the drug companies for one five-week span last summer. During that time, and in 17 hours of meetings with drug company sales representatives, Ibrahim was approached by 16 multinational pharmaceutical companies, including 10 of the world's 20 largest drug manufacturers, and nine local generic drug makers and distributors. The following is a partial listing of the companies that contacted or visited Ibrahim, and the materials or gifts that they brought him:

•Pfizer., AstraZeneca Plc, Novo Nordisk A/S and GlaxoSmithKline Plc – provided Ibrahim a half-dozen updates on drugs or treatments

•Pfizer, Merck Sharpe & Dohme, Boehringer Ingelheim GmbH, Bayer AG and Abbott Laboratories Inc. – stopped by Ibrahim's office 10 times to give him pens

•Abbott Laboratories – visited Ibrahim once to give him plush toys

•Pfizer, MerckSharpeDohme and Sanofi-Aventis – gave Ibrahim plastic promotional folders on four separate occasions

•Bayer, Pfizer, Sanofi-Aventis, Boehringer Ingelheim and Abbott Laboratories – visited Ibrahim five times with small gifts like tissue boxes, soap, mouse pads and bags

•Sanofi-Aventis, Novartis International AG, Bayer and Abbott Laboratories – offered event sponsorships and/or dinners on five occasions

Ibraham's report startled Consumers International officials, yet they acknowledge that such gift-giving by the drug companies is routine, and in many cases, much more extreme. The organization chalks this up to poorly enforced or ineffective regulations in the developing world.

"In developing countries, the systems and resources to effectively monitor and regulate the marketing of medicines are not necessarily in place," the report states. "In 2004, the World Health Organization established that less than one-sixth of countries had a well-developed system of drug regulation, and one-third had little to no regulatory capacity. Therefore, frameworks to enforce unethical, irresponsible or even illegal promotion to consumers are a major problem in the context of developing and emerging economy countries."

Consumers International faults both the doctors and the drug companies for contributing to the spread of these problems, but it levies its harshest criticism at the pharmaceutical industry for rejecting calls to end kickbacks to the doctors. The group also says that the industry’s policy of self-regulation has failed, citing advertisements by drug makers GlaxoSmithKline, Wyeth, Novartis and Pfizer that would be considered misleading in the United States and Europe, as well as the heavy promotion by all companies of products to doctors.

“Consumers International believes the best way to ensure patients in the developing world get rational, impartial treatment from their doctor is for governments and the pharmaceutical industry to ban the practice of giving gifts to doctors entirely,” Lloyd, the organization’s director general, said.

The drug industry opposes government regulation of drug promotion on the grounds that advertising and promotion are essential for informing health-care professionals about new medicines and new uses for existing medicines. Self-regulation, via the International Federation of Pharmaceutical Manufacturers and Associations Code of Pharmaceutical Marketing Practices, supplemented by member association and company codes, is the industry’s response to ensuring appropriate standards are met in this respect.

The International Federation of Pharmaceutical Manufacturers Associations – the drug industry’s global trade body – said that it would need time to get its code of conduct adopted worldwide. “I think it is not something that is achievable overnight,” federation spokesman Guy Willis said. “The issue is how do we get there.”