Sleeping with the enemy? Ethical behaviour talk amidst physician-pharma interface

By Dr Amitav Banerjee, MD* 
In recent weeks a flutter was created around a gazette hastily released by the National Medical Commission (NMC) on the Code of Conduct by Registered Medical Practitioners of modern medicine. 

Clause 35 of the Gazette notification, dated 02 Aug 2023 and published on 09 Aug 2023, which has been paused due to push back from many quarters, including the Indian Medical Association (IMA), looks at any alliance between registered medical practitioners of modern medicine and the pharmaceutical industry with a jaundiced eye.
The gazette notification conveys the paranoid attitude of the NMC that any liaison between doctor and the industry is not above board and is rife with conflicts of interest. The attitude of the regulating body consisting of nominated members is reminiscent of an authoritative regressive society where no mixing of the genders was allowed. 

 In such societies any liaison, even between consenting adults of opposite sexes, is considered stigmatizing and has to be above board under the watchful eyes of the parents, if at all that is.
Similarly, according to the NMC diktat, which has been held in abeyance, one should be thankful for small mercies, all doctors are supposed to undergo Continuing Medical Education (CME), now renamed as Continuing Professional Development (CPD), in the form of conferences and workshops which will be free of any pharma sponsorship or funding. Needless to say, doctors should not accept any tours, travels, free lunches, or gifts from the industry.
Fair enough, one should not let your partner shower you with expensive gifts on a first date! But the paternalistic attitude goes further. According to the gazette, doctors need to acquire 30 credit points in a cycle of five years for the renewal of their licenses. This credit points are collected by attending medical conferences and workshops.
As these conferences cannot be sponsored by pharmaceutical industry, they are to be held at NMC approved institutions and the contents of the conferences and workshops will also be closely monitored by the NMC. 

What is to be taught and discussed in these workshops will be decided by the NMC – like a school syllabus! And these diktats are for professional doctors, some with specialist and superspecialist qualifications and many having considerable professional experience.
What can be the reasons for the practitioners of modern medicine to find themselves in this predicament? In recent years while medical advances have enabled many medical miracles, the cost of medical treatment has gone up exponentially due to costly diagnostics, interventions and rise in chronic diseases as a result of increasing lifespan. Along with it inequities in access to health services have increased as well.
The doctor who is working downstream is seen as the face of the medical establishment and faces the wrath of patients and society. But will the isolation of the medical fraternity from industry solve the problem?
Shall we cut the collaboration of the industry with the profession which has propelled great medical advances? Louis Pasteur’s work on rabies vaccine led to the rise of the vaccine industry. Alexander Fleming’s discovery of penicillin changed the course of medical history and spawned the huge pharmaceutical industry. 

These are some shining examples of the benefits of scientists and doctors collaborating with the pharmaceutical industry.
However, there have been shameful misconducts by the members of the profession for personal gains as well. They include fabrication of data from clinical trials to favour the sponsors from the industry and carrying unnecessary diagnostic tests, treatments and surgeries. 

It is these instances which have made some groups lobby for cutting all ties of doctors with the industry – while those who support the physician-industry interface give examples of the spectacular advances resulting out of it.
These two extreme viewpoints have polarized the debate while the need of the moment is to regulate the vast grey zone which falls between these two.
Presently, the contribution of pharmaceutical companies to global health research is substantial. When compared with the research budget of government sources and international health agencies like the WHO and UNICEF the combined aid of pharmaceutical industry rivals and even exceeds those of public sources.
The future will see more and more application of artificial intelligence, machine learning, surgical robotics, telemedicine, disease diagnostic software, newer medical devices and other emerging technologies being applied in medical and health care.

A health policy maker in the WHO or the ICMR has more conflicts of interest than a hundred doctors with stethoscopes

To advance these technologies to their full potential will require doctors to collaborate not only with the pharmaceutical industry but also other industries such as engineering and information technology. It is not only politics which make strange bedfellows. 

For in spite of various conflicts of interests which the interface between the industry and the profession is likely to generate, sleeping with the enemy is inevitable because of the following reasons:

• Medical progress is good and benefits humankind.
• Industry is responsible for a large amount of medical progress.
• Fine tuning industry driven technological advancements for medical application will require active participation of doctors.
• Isolating the medical profession from the medical industry will result in teaching tomorrow’s doctors yesterday’s medicine.

Given the inevitability of the increasing interface between doctors and the industry how can we ensure ethical behaviour on the part of both the parties, without doctors becoming victims of seduction? This can be achieved by:

• Teaching medical students and physicians “critical thinking skills” to enable them to differentiate between sound clinical information (good touch) and promotional literature without any evidence base (bad touch). They should be able to appraise evidence and not swayed by propaganda.
• Promoting “good relationship practices” which cultivate scientific interactions leading to enhancement of skills that will benefit the patient and community without the possibility of the interaction being viewed as an inappropriate or questionable activity.
• Ensuring “transparency,” “empowerment” and “accountability” from both parties during healthy networking

August bodies like the WHO and even our ICMR have collaboration and networking with the pharmaceutical industry. Currently, the WHO has control over only a quarter of its budget. WHO therefore cannot set the global health agenda and has to do the bidding of rich donors. 

The Gates Foundation itself is responsible for over 88% of the total amount donated by private foundations to the WHO. The Indian Council of Medical Research (ICMR) has also inked a "Declaration of Intent" with the Gates Foundation for collaboration in health research.
Interestingly, in 2013, the Joint Parliamentary Committee had tabled a report (72nd report) to both houses of Parliament indicting the Gates Foundation (PATH) and the ICMR of major ethical violations during conduct of trials of HPV vaccine leading to deaths of tribal girls.
Howzzat NMC!
The real conflicts of interests are upstream at the level of the WHO and ICMR rather than at the downstream where the humble doctor is treating individual patients. The statement, “A lawyer with his briefcase can steal more than a hundred men with guns,” is attributed to Mario Puzo, the author of "Godfather". In the same way, a health policy maker in the WHO or the ICMR has more conflicts of interest than a hundred doctors with stethoscopes.
These conflicts of interests upstream become more concerning in view of the proposed Pandemic Treaty by the WHO. Dr David Bell, a former senior scientist with the WHO, has cautioned that this treaty can lead to perpetual lockdowns and threaten autonomy of nations who sign this treaty.
The treaty will create a bureaucracy whose existence will depend on pandemics. They will have vested interests in finding outbreaks and declaring them as potential pandemics. And they will make lockdowns a permanent feature of pandemic response. The influence of corporate on decision making by the WHO has surfaced frequently in recent times.
Similarly, besides signing a “Declaration of Intent” with the Gates Foundation, the ICMR also collaborated with the vaccine industry during the recent pandemic. And more interestingly, with its skin in the game the ICMR is investigating vaccine related adverse events!
NMC, please note.
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*Professor in a Medical College in Pune; earlier served in the Indian Armed Forces as a field epidemiologist; currently Chairperson, Institutional Ethical Committee, National Institute of Virology, Pune (ICMR), and Chairperson, Institutional Ethical Committee, Armed Forces Medical College, Pune; formerly Chairperson, Institutional Ethical Committee, Chellaram Diabetic Institute, Pune