Like twin rivers in spate, several thousand people flow down parallel pavements the length of Munich's vast conference halls. Here and there, a signboard held by a rep bobs above the flow. They are heading for the car park, where dozens of buses hired by drug companies are waiting to take them to dinner. These are not package tourists, but doctors.
This is the main annual European conference for cardiologists - a huge affair of 18,000 delegates. Most travel there courtesy of the drug companies. They have their registration paid, their flight paid, their hotel paid and their meals paid. Out of courtesy, they attend the "satellite symposium" before dinner promoting their sponsor's drug.
Many senior doctors or "opinion leaders" hired to speak on behalf of the drug companies at these events will sleep in the best hotels and collect between £1,000 and £2,000 for their talk, if they are not already on an annual retainer of £10-20,000 from each company they advise.
Most doctors say the sponsorship of doctors by the drug companies is normal, inevitable in a capitalist society, and does no harm because, they insist, they are not influenced. Others say it is shocking. Raymond MacAllister, senior lecturer in pharmacology at University College London, believes the profession is under a mass delusion. "If the general public knew what was going on, they would be astonished," he said.
Edwin Gale, a professor of diabetes at Bristol University's division of medicine, once took drug industry money but changed his mind after he was asked to investigate a class of drug by a colleague who wanted somebody "who is not in the pocket of the companies". He was shocked to discover that the drugs had been kept on the market in the US for three years after it became clear that people were dying of liver failure.
In an article he was asked to write for Clinical Medicine, the journal of the Royal College of Physicians, last November, he analysed the science that shades into marketing, the professors who end up as promoters, and called on each doctor to make a moral decision about their own involvement. Most do not recognise what is happening, he said. "Doctors are so incredibly gullible because they suspect themselves of the very highest motives."
The article brought him support even from some scientists in the employ of industry, he said. "They said they are sickened by the process they are involved in. One said I just wondered when doctors were going to wake up to what is going on."
There are rules on gifts to doctors - nothing much more than a pen or a coffee mug is allowed. So in the Munich exhibition halls, vast as aircraft hangars, the big companies run quizzes at their space-age stands. Doctors sit on stools at a table, fingers on buzzers, or crowd round the posters filling in questionnaires about the company drugs. It is every one a winner and they walk off with a digital camera, a calculator or silver computer mouse. Many doctors wander the stands with bags crammed with booty.
Sponsorship is part of the NHS fabric. Every doctor must keep up to date with about 50 hours of continuing medical education a year. Five days in Munich listening to the scientific presentations at the European Society of Cardiology meeting nets a doctor 18 hours of credits. But the NHS has a limited pot of money, so in fields like cardiology, psychiatry and rheumatology where drugs are big business, the companies step in.
Everything is paid for. The Munich hotels had drug company desks in the foyers, with schedules of dinners and the industry's satellite symposia times on the noticeboards and buses that drew up outside after breakfast and dropped doctors back after dinner.
In the company sights, says a cardiologist who attended the Munich conference but does not want to be named, is the hospital formulary. This is the list of drugs, drawn up by a committee, that the hospital consultants can prescribe for their patients, who then get the prescription continued by the GP.
"There is overt pressure," he said. "the local hospital drug reps come to us and say - will you make an application to the formulary committee? You have to be able to argue back to them." Those doctors who refuse to help will be out of favour come conference time, he said. He did once make an application to the formulary committee because he was impressed by a certain heart drug. It was accepted. As far as the drug company was concerned, he "was the cat's pyjamas. The year after they took me to America for a conference. I was comfortable with what I had done, but you can see how easily that becomes a trap to fall into," he said.
A study in the Journal of the American Medical Association in 2000 showed that the more free meals a doctor has from a drug company, the more often he is likely to ask for their drug to be put on the approved list. Also associated with such requests is meeting drug reps, accepting funding to travel to conferences and accepting research funds.
Dr MacAllister says the formulary committee he sits on in his large teaching hospital is robust. "But in a district general hospital, they are more likely to say - he's the heart specialist - let him have it."
There is still more concern about the independence of senior doctors, often involved in drug trials for the industry, who are recruited by the companies as consultants and can earn considerable amounts of money speaking to conferences about new drugs and giving companies advice on marketing their products. In the trade, such an authoritative academic is known as a "silvertop".
Professor Gale had a consultancy around six or seven years ago: "I was earning about £25,000 a year (extra), of which £20,000 was formally a consultancy fee.
"I know people who have been offered £30,000 to £50,000 a year to sit on advisory committees," said Dr MacAllister. A colleague was paid £800 by a company when a talk he was to give was cancelled. Robin Murray, professor at the Institute of Psychiatry, who said he could be offered $2,000 for a talk which he would put into his research fund, said the issue was not with the drug companies, but with the clinicians. "You don't necessarily expect your colleagues to speak in support of whatever drug they are being paid to support. It is very dismaying to find academic psychiatrists that one has hitherto respected supporting one drug on a Monday and another on Tuesday," he said.
Increasingly, he said, academics are putting their names to drug trial research papers which are "ghost-written" by company employees. "Academics, particularly academic pharmacologists, have somehow begun to believe that it is acceptable to present company data as if they were a hired gun," he said.
If the audience knew those academics had not taken part in the collection of the trial data, he said, "they would be much less impressed." But the doctors who advise companies and carry out research say the concern is misplaced.
Philip Poole-Wilson, professor at the National Heart and Lung Institute of Imperial College, London, who was the lead author in a trial of Bayer's drug nifedipine and spoke at their satellite symposium in Munich, said it was up to individuals to obey their consciences.
"I'm not going to be manipulated by any company, by any amount of people or anybody. I'm going to say what I want to say and that's that. I regard myself rather like a barrister - that I'm a cardiologist, I know the subject, I'm prepared to speak on it when invited and if I am invited I expect to be paid."
John Betteridge, professor of endocrinology and metabolism at University College London, who also spoke in Munich and has declared interests in seven pharmaceutical companies as an expert adviser to the Committee on the Safety of Medicines, maintained that doctors were independent of drug company influence. "I think it would be very unusual if doctors used drugs if they thought they weren't the best for that particular patient," he said.
Nonetheless, a paper produced by the Pharmaceutical Marketing journal suggests "opinion leaders" are carefully recruited and groomed.
It urges "careful identification of the people you should be working with. The key is to evaluate their views and influence potential, to recruit them to specially designed relationship-building activities and then provide them with a programme of appropriate communications platforms."
Joe Collier, professor of medicines policy at St George's school of medicine in London, said: "Here is an industry that abuses its power to manipulate what is being prescribed. The cynicism ... seems to know no bounds."
