The traditional independence of physicians and the welfare of the public are being threatened by the new vogue among drug manufacturers to promote their products by assuming an aggressive role in the "education" of doctors. In the recent Congressional investigation of the cost of drugs it was repeatedly stated by executives of pharmaceutical concerns that a major expenditure in the promotion of drugs was the cost of "educating" physicians to use the products-and they mean doing what has always been expected of medical institutions. Is the public likely to benefit if practicing physicians and medical educators must perform their duties amidst the clamor and striving of merchants seeking to increase the sales of drugs by conscripting "education" in the serv

The author submitted this manuscript for critical review to the Physician's Council-an independent group of eighteen eminent physicians who organized in 1956 "to seek means of maintaining high standards for the material on health that is disseminated through the media of mass communication." The Physicians' Council wishes it to be known that it endorses this essay as an accurate, equitable, and constructive analysis of matters of major importance in relations between the medical profession and the pharmaceutical industry. Reprints will be available from the Physicians' Council, 2 East 63rd Street, New York 21, N. Y.

Dr. May is now Professor, Department of Pediatrics, New York University College of Medicine.

ice of promotion? Is it prudent for physicians to become greatly dependent upon pharmaceutical manufacturers for support of scientific journals and medical societies, for entertainment, and now also for a large part of their education? Do all concerned realize the hazard of arousing the wrath of the people by an unwholesome entanglement of doctors with the makers and sellers of drugs?

That these are grave and pressing questions and not trivial fears should become apparent in the ensuing presentation of problems that surely deserve the serious attention of manufacturers, prescribers, and consumers of drugs. No one can be oblivious to the many fine contributions of both doctors and drug companies that certainly deserve the greatest admiration, but the dark side of things must be fully explored if the origins of the present problems are to be determined. The higher purpose of this analysis is to halt practices which are undermining sound medical care as well as degrading the reputation of the pharmaceutical industry and lowering the prestige of the medical professionto a degree that has already aroused public concern and the probings of politicians.

After a general discussion of the dee terious practices, some specific proposals

ACHROMYCIN V

TETRACYCLINE AND CITRIC ACID

ACHROMYCIN Tetracycline is universally recognized as the superior antibiotic for the control of a wide range of susceptible organisms. Constant research at Lederle has resulted in an antibiotic expressly designed to accentuate rapid diffusion into body tissues and fluids, with minimal side effects. High and fast blood levels are achieved for more competent control of the disease under treatment.

for unexcelled antibiotic action

LEDERLE LABORATORIES, A DIVISION OF AMERICAN CYANAMID COMPANY PEARL RIVER, NEW YORK

FIGURE 2

to consistently disseminate reliable information. The soundness of this assumption can be tested by a look at some current specimens of advertising. These items are from a considerable supply of the same kind, and regular scrutiny of the torrent reaching the physician will satisfy the curious that similar examples are easy to find. It will be seen that well known firms are guilty of sponsoring dubious "educational" material on topics of vital importance, and so the physician is left without any assurance of authenticity except from his own wits.

Antibiotics. Antibiotics are therapeutic agents which no one can deny should be used intelligently and with discrimination. Efforts to influence physicians to prescribe these valuable remedies on an unsound basis would be particularly unfortunate; only clear and accurate information should reach the doctor.

For the past 3 years major pharmaceutical companies have been engaged in a competitive struggle to increase the sales of their particular brands of antibiotics by a confused and misleading barrage of promotion (Figs. 1-3). The exuberant campaign was based on meager and poorly controlled observations on the levels attained in the blood by

various preparations of antibiotics; additions of certain agents (phosphate, citric acid, glucosamine) were claimed to enhance the absorption of antibiotics and enable higher levels to be reached in the blood more promptly.

Soon after this hectic campaign was well under way, the premise was chai lenged (9, 14): actually, the action of these agents was to neutralize the unfortunate effects of fillers used in the capsules of the antibiotics-these were calcium salts that combined with the antibiotics and hindered their absorp tion. When the various forms of antibiotics are administered to fasting persons without fillers, no advantage is observed from addition of phosphate. citric acid, or glucosamine to the plair parent compounds (10). Furthermore, no sound evidence was ever brought forth that the levels and speed of absorption claimed for the widely heralded derivatives offered any practical clinical advantage or therapeutic superiority.

Pointed criticism from competent authorities did not check the eagerness with which the promoters undertook to "educate" the physicians with inadequate and irrelevant data and misleading claims in material distributed for the drug companies. Note the triumphart tone in the examples of promotional material from this campaign-this is the sort of inconsequential contribution the industry sometimes refers to proudly as the result of great investment in research in the companies' own laborstories. This achievement consisted of getting rid of the inhibiting effects of filler the manufacturer customarily used in the capsules of such products.

The "educational" effect on doctem was to confuse them and lead them t believe wonderful new drugs were avai able and that minor differences in blood levels and the rate of absorption are significant therapeutic advantages.

Similar tactics are now being applied

a derivative of penicillin (Fig. 4). he same substance is put forth under t least six brand names as if it were he discovery of each distributor. It is Iso slyly touted as synthetic penicillin hen it is only a chemical modification Of a fermentation product that is not olated in pure form (15). The same hatter about higher levels being atained faster, without proof of clinical dvantages, characterizes this latest educational" material reaching the -octor. Once again evidence is lacking

prove the clinical superiority of the ew derivative; the old penicillin V can

be absorbed about as well if adminis tered on an empty stomach (13),

No amount of pleading (7) has discouraged the pharmaceutical industry from marketing and pushing products made up of mixtures of antibiotics. An example of low regard for the intellect of the average doctor is the promotion of Panalba by Upjohn (Fig 5), where one is asked to belive an in vitro menel tivity test is a demonstration of clinical "performance in pneumonia" (no refor ences to clinical trials) The nature of this combination is kept obscure by giv ing the company's brand names of the ingredients. What will this kind of "edu