Introduction

How MaLAM began

Misleading promotion is an emotional issue. However, it deserves the same calm, rational examination as any other medical issue. David Morley's Paediatric priorities in the developing world suggested that a problem deserves priority if it is common, severe, a cause of community concern and amenable to therapy.⁶ My personal experience in Bangladesh led me to believe that misleading promotion met the first three criteria. More recently, much good evidence has become available which is relevant to these three criteria (see Box). Interestingly, this evidence comes from the developed world, where the impact of misleading promotion on health is probably less severe than it is in the Third World. However, at the time, the challenge for me was to conceive and then implement a "therapeutic" arm to deal with what had become a personal priority -- the problem of misleading pharmaceutical promotion in the Third World.  

How MaLAM works

Having been a member of Amnesty International, I was familiar with that organisation's strategy of coordinated letters: members would be asked to send letters on particular issues to relevant individuals or bodies. I decided to adopt a similar strategy and anticipated that subscribers, via their subscriptions, would cover postage costs. I would provide the "labour" for free, hopefully with volunteer assistance.

Before commencing, MaLAM was registered under the South Australian Associations Incorporation Act, which provides a legal basis for good governance and financial accountability for organisations with small or large budgets.  

MaLAM and the Third World

MaLAM editions, produced monthly, usually comprise a newsletter and a letter to a pharmaceutical company about one or more of its promotional claims. Each letter includes a summary of the relevant scientific literature and invites the company to justify or amend its claims. Subscribers also receive a support letter, which they can sign and post to the company so as to request a copy of its reply.

Topics are selected from the up to 200 advertisements we receive per month from concerned health professionals. Many MaLAM editions have focused on misleading promotion of drugs, which have an important place when used appropriately but could be dangerous or ineffective if misused. We have also chosen to write to companies when advertising is most seriously at variance with the scientific literature. While it is often difficult to assess how large a role MaLAM played in "causing" improvements, the temporal relationships are usually clear.

Our first major success was a letter in 1986 requesting evidence to support the promotion of a mixture of arsenic, strychnine, vitamins and alcohol for stress in Pakistan. The manufacturer announced a withdrawal immediately. In the same year, our editions also became available in French. By 1991, pharmaceutical companies had promised to withdraw 11 drugs after receiving MaLAM letters. The most important of these was a chloramphenicol/streptomycin combination, which had been the top-selling over-the-counter product for diarrhoea in the Philippines.

We also published a classification of the quality of "evidence" used by pharmaceutical companies to justify efficacy claims when their advertising was questioned. Some companies provided no justification. Others used the following types of arguments: "endorsement by their own staff", "other companies do the same", "government approval" (without any other evidence), "longstanding use", "endorsement by experts", "animal or in-vitro studies", or "clinical trials" which in fact had major methodological flaws. ¹⁸

We believe that pharmaceutical companies are more concerned about their image in "major" markets (i.e., in developed countries) than their relatively small profits from poor countries. Further, because pharmaceutical company executives seem to think in political more often than in scientific terms, it was important for them to know that MaLAM reflects the concerns of large numbers of health professionals rather than a government or fringe agenda. MaLAM's design addresses this by involving large numbers of subscribers in the dialogue as the final quality control step. Subscribers, mostly doctors or pharmacists, now number over 6000, spanning over 30 countries. Accordingly, our impact has increased.  

MaLAM in Australia

Between June 1993 and August 1996, MaLAM initiated dialogue about the promotion of 17 drugs in Australia. All companies but one have replied. Advertisements for seven drugs that we provided feedback about are no longer used.

While the Australian edition appears popular with local subscribers, it is not as effective as the International edition in leading to improvements in marketing pharmaceuticals. The scientific issues are more subtle and the profits involved are greater; companies seem less willing to make improvements. We believe companies have sometimes reacted by interpreting our words in a severe and extreme way, allowing them to criticise easily rather than to respond to our real concerns. Fortunately, some companies seem to understand that listening to "customers" may help them to make more money in the long term. There is an encouraging trend towards a more sophisticated market which will reward quality by favouring drugs that come with reliable information so as to produce the best health outcomes.  

MaLAM in the future?

In the future, MaLAM may be able to offer more to health professionals. We would like to increase our contribution to medical education because many subscribers have reported that they find MaLAM a fascinating way to improve their critical-appraisal skills. It is also an interesting way to be up to date on the other side of the story about specific drugs, often at a time of important controversies. For example, our international contacts enable us to draw attention to adverse effects which were well documented in languages other than English before they were listed in the Australian product information.

There is also a need for ongoing measurement of the impact of promotion on prescribing, especially the effect of pharmaceutical sales representative visits. If the impact can be measured, then the efficacy of interventions to reduce the harmful consequences of promotion could be tested.

While it has been suggested that doctors can learn "to sort the wheat from the chaff",^21,22 critical-appraisal skills will not protect against the more subtle methods of influence. Therefore, the best that we can do about pharmaceutical promotion is to try to avoid it or improve it. Personally, I am not in favour of the adversarial approach, and believe that pharmaceutical companies will make improvements if they receive a strong signal from the market. If we work together, then we will be able to protect scientific medicine from misleading promotion.  

Acknowledgements

1. I thank Robyn Clothier, Joel Lexchin, and Agnès Vitry for their comments.

References

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