Containing Global Antibiotic Resistance: Ethical Drug Promotion in the Developing World
The introduction of antimicrobial agents was a breakthrough health intervention that helped save millions of lives around the world and that provided a sense of control on the part of clinicians over host–pathogen interactions. Yet despite the concrete advances in prevention and treatment of infectious diseases, there has been a parallel surge in resistance to antimicrobials that is seriously compromising the gains made over the past century. Acknowledging the underlying mechanisms such as inappropriate use of antibiotics in humans and the agricultural applications of antibiotics for growth promotion and prophylaxis is a first and essential step to contain global antimicrobial resistance. However, it is also critical to consider in parallel the broad social, economic and political drivers and ethical significance of antimicrobial promotion in developing countries. Moreover, these socio-ethical factors constitute tangible targets against which public policy interventions can be developed to remedy growing concerns over the spread of antimicrobial resistance. In this chapter, we focus on drug promotion practices in the developing world that have important repercussions on physician prescribing habits, antimicrobial use and development of resistance. Other social factors that are endemic in developing countries – such as inadequate resources in health and education systems – can amplify erratic or suboptimal drug use. The public health consequences of, and ethical responsibilities associated with, drug promotion are substantially larger when viewed through the prism of the realities faced by persons living in developing countries. In our world of increasing urbanization and globalization, the actions of pharmaceutical companies have a global impact. Thus, their social responsibilities extend beyond developing medications for the populations of the developing world, to include socio-ethical and public health consideration for populations worldwide. Focusing on the fact that ‘what happens in the developing world does not stay in the developing world’, we propose that ethical considerations should be included as an integral part of the framework in the evaluation of appropriateness of drug promotion practices.
KeywordsPharmaceutical Company Antimicrobial Resistance Antimicrobial Drug Promotional Material Ethical Criterion
Supported in part by an ethics operating seed grant from the Canadian Institutes of Health Research and a career scientist award in ethics, science and society research from the Fonds de la recherche en santé du Québec to Vural Ozdemir. We thank Anne-Marie Dion for constructive critique and expert advice on pharmaceutical advertising and promotion. Catherine Olivier was supported by a fellowship from the Centre de Recherche en Éthique at the University of Montreal, and from the Canadian Institutes of Health Research. The ideas expressed represent the personal views of the authors only.
- BBC News. 2005. Brazil may break Aids drug patent. Brazil has threatened to break the patent on an anti-Aids drug in order to make a cheaper generic version. http://news.bbc.co.uk/go/pr/fr/-/2/hi/americas/4621735.stm.
- BBC News. 2007. Uganda opens first HIV drug plant. A factory that will produce treatments for HIV/Aids is opening in Uganda, the first of its kind in the country http://news.bbc.co.uk/2/hi/africa/7033162.stm.
- Benkimoun, P. 2005. Le paludisme, un tueur du tiers-monde. Le Monde. Paris.Google Scholar
- Bhutta, T. I. 1996. Deception by design: pharmaceutical promotion in the Third World. Br Med J 313:60.Google Scholar
- Dipeolu, M. and Alonge, D. 2002. Residues of streptomycin antibiotic in meat sold for human consumption in some states in Nigeria. Arch Zootec 51: 477–480.Google Scholar
- Donald, A. 1999. Technology transfer: the problem with “trickle down” theory. Br Med J 319: 1298–1299.Google Scholar
- Dugger, C. W. 2007. U.N. predicts urban population explosion. The New York Times. New York.Google Scholar
- Garcia-Rey, C., Aguilar, L., Baquero, F., Casal, J. and Martin, J. E. 2002. Pharmacoepidemiological analysis of provincial differences between consumption of macrolides and rates of erythromycin resistance among Streptococcus pyogenes isolates in Spain. J Clin Microbiol 40: 2959–2963.CrossRefPubMedGoogle Scholar
- Gassman, N. 1999. Social and economic value: two sides of the self-medication coin. Responsible self-medication: a challenge to consumers and industry. The World Self-Medication Industry (WSMI) 13th General Assembly, The Association of the European Self-Medication Industry (AESGP) 35th Annual Meeting, Self-care – a vital element of health policy in the information age. Berlin.Google Scholar
- Harris, G. 2007. Minnesota limit on gifts to doctors may catch on. The New York Times. New York.Google Scholar
- Hart, C. A. and Kariuki, S. 1998. Antimicrobial resistance in developing countries. Br Med J 317: 647–650.Google Scholar
- Heath, J. 2006. Business ethics without stakeholders. Bus Ethics Q 16: 533–557.Google Scholar
- Hogerzeil, H. V. 2004. The concept of essential medicines: lessons for rich countries. 329: 1169–1172.Google Scholar
- Menkes, D. B. 1997. Hazardous drugs in developing countries. Br Med J 315: 1557–1558.Google Scholar
- Mintzes, B. 1998. Blurring the boundaries: new trends in drug promotion. In: Promotion Targeting Consumers. Amsterdam: HAI-Europe www.haiweb.org/pubs/blurring/blurring.intro.html Dated Accessed January 20, 2009.
- MSNBC. 2006. WHO calls for halt on malaria treatment. Agency fears improper use may lead to drug resistance. Associated Press.Google Scholar
- Mutume, G. 2001. Health and intellectual property; poor nations and drug firms tussle over WTO patent provisions. Africa Recover 15(1): 14–15.Google Scholar
- Norris, P., Herxheimer, A., Lexchin, J. and Mansfield, P. 2005. Drug promotion. What we know, what we have yet to learn. Reviews of materials in the WHO/HAI database on drug promotion. Amsterdam: WHO/HAI.Google Scholar
- Oyugi, J. H., Byakika-Tusiime, J., Charlebois, E. D., Kityo, C., Mugerwa, R., Mugyenyi, P., et al. 2004. Multiple validated measures of adherence indicate high levels of adherence to generic HIV antiretroviral therapy in a resource-limited setting. J Acquir Immune Defic Syndr 36: 1100–1102.CrossRefPubMedGoogle Scholar
- Ozdemir, V., Graham, J. E. and Godard, B. 2008. Race as a variable in pharmacogenomics research: From empirical ethics to publication standards. Pharmacogenet Genomics 18(10): 837–841.Google Scholar
- Talbot, G. H., Bradley, J., Edwards, J. E., Jr., Gilbert, D., Scheld, M. and Bartlett, J. G. 2006. Bad bugs need drugs: an update on the development pipeline from the Antimicrobial Availability Task Force of the Infectious Diseases Society of America. Clin Infect Dis 42: 657–668.CrossRefPubMedGoogle Scholar
- World Consumer Rights Day (WCRD). 2007. Unethical Drug Promotion.Google Scholar
- World Health Organization. (WHO) http://www.who.int/medicines/en.
- World Health Organization. (WHO). 1988. Criteria for medicinal drug promotion. Geneva: World Health Organization.Google Scholar
- World Health Organization. (WHO). 1998. Emerging and other communicable diseases: antimicrobial resistance. Geneva: World Health Organization.Google Scholar
- World Health Organization. (WHO). 2001. Pharmaceutical promotion. IN WHO global strategy for containment of antimicrobial resistance. Executive Summary, World Health Organization (Ed.). 51–53. Geneva: World Health Organization.Google Scholar
- WHO. 2006. Facts on acts (artemisinin-based combination therapies). Geneva: World Health Organization.Google Scholar
- WHO. 2007. Resistance to artemisinin derivatives along the Thai-Cambodian border. Weekly Epidemiol Rec 82(41): 360.Google Scholar