Introduction
A trip to Paris in September 2006 cost Dr. D. Gray Heppner nothing. GlaxoSmithKline, one of the world’s largest drug manufacturers, paid $7,800 for the lieutenant colonel and chief of the Walter Reed Army Institute of Research’s Department of Immunology to attend the company’s symposium on malaria.
It was Boston in May for John W. Szabo. Medical device manufacturer Cardinal Health paid $5,000 for Szabo, then chief of the Pharmacy Service at the U.S. Army Health Clinic at Schofield Barracks in Hawaii, to attend a leadership conference in 2002. The year before, Szabo went to a diabetes conference in Austin, Texas, and GlaxoSmithKline paid the bill through an unrestricted grant, totaling more than $1,000.
Trips to Tampa Bay and Austin in 2000 for Peter Bulatao were paid for by drug-makers Novartis and GlaxoSmithKline. Bulatao, then chief of the Department of Pharmacy at Lyster Army Community Hospital, in Fort Rucker, Ala., sat on the committee responsible for selecting drugs for the hospital.
These were among 8,700 trips by Department of Defense personnel paid for by the health care industry — at a cost of more than $10 million — from 1998 through 2007, according to an analysis by the Center for Public Integrity. In a joint project with Northwestern University’s Medill School of Journalism, the Center examined 22,000 travel disclosure forms filed by DOD personnel, and found that the medical industry was by far the biggest sponsor of free travel, accounting for about 40 percent of all trips. The sponsors included not only drug and device makers but also health foundations and trade groups often funded by those companies.
A $6 Billion Drug Market
Of special interest to the industry were DOD employees who prescribe, purchase, or recommend the use of drugs or medical equipment. Drug companies and device manufacturers spent about $1.7 million for more than 1,400 trips taken by DOD doctors, medical researchers, pharmacists, and other health care employees over the decade, creating relationships that pose serious conflict of interest issues, according to medical ethics experts. From 2000 to 2006, the DOD prescription drug budget ballooned from $1.6 billion to more than $6 billion a year.
Shahram Ahari says he is familiar with this game. While working as a sales representative for the drug company Eli Lilly & Company in 1999 and 2000, Ahari describes how he used free meals, trips, and unrestricted grants to subtly seduce civilian physicians into prescribing the firm’s drugs. The strategy, Ahari explains, is to make friends with doctors and pharmacists, get them talking about a company’s drugs or devices, and then reward them with additional perks for prescribing their drugs. Often physicians do not even realize the company is manipulating them.
“The return on dividends is phenomenal,” Ahari says. “If it costs them a thousand dollars for a dinner, that’s a [patient’s drug] payment for one month. If they fly you on the Concord to Paris for five grand, even if they get one patient out of it, it’s a lifetime of cash.”
Among the top medical device manufacturers or pharmaceutical company sponsors of trips for DOD personnel are:
- Johnson & Johnson, 187 trips at a cost of more than $215,000;
- GlaxoSmithKline, 95 trips at a cost of more than $120,000;
- Hologic Company, 37 trips at a cost of more than $102,000;
- Medtronic Inc, 86 trips at a cost of more than $93,000;
- Smith & Nephew, 81 trips at a cost of nearly $90,000.
Medtronic made the front page of the New York Times in May after an Army investigation found that military surgeon Dr. Timothy R. Kuklo overstated the benefits of Infuse, a drug sold by Medtronic and used to treat combat-related bone injuries. The Army investigation revealed that Kuklo, a paid Medtronic consultant, falsified information and forged the signatures of colleagues as co-authors in a British medical journal article. According to the Center’s analysis, between 2001 and 2006, Medtronic paid for at least 15 trips taken by Dr. Kuklo, worth more than $13,000. Among the destinations were Coral Gables, Florida, and Scottsdale, Arizona.
Representatives of these companies say they follow the law and government regulations closely, paying only for reasonable expenses tied to professional trips or third-party meetings. But industry-sponsored travel has become a hot topic in the medical community, prompting criticism by bio-ethicists, elected officials, and professional organizations.
Medical professionals and industry often partner to improve medical treatment, according to Dr. Heppner, now deputy commander of the Walter Reed Army Institute of Research. He says the institute could not create the vaccines and diagnostic services needed to protect the health of American military personnel without partnering with drug companies, as the institute lacks the necessary funding and technological capabilities to act alone. His trip to Paris, paid for by GlaxoSmithKline, represented a critical element of this partnership by allowing the U.S. government to receive credit for working on a malaria vaccine. “It is important to me that people understand the important things we bring and I felt that I had to represent our contributions to the world,” Heppner says.
Among the most prolific travelers in the Department of Defense is Dr. Norman Rich, a surgeon and professor at the Uniformed Services University of the Health Sciences. The doctor, a pioneer in vascular surgery during and after the Vietnam War, took about 80 trips valued at more than $250,000, including about $20,000 from Johnson & Johnson. Allowing Rich to take industry-funded travel, officials say, allows him to share his knowledge with surgeons across the globe.
“Is it normal for the faculty here? The answer is no,” says Bill Bester, the school’s acting vice president for external affairs, said of the trips taken by Rich. “But Dr. Rich has 40 years of surgical experience. He is known nationally and internationally. There’s probably no one living who’s contributed more to military surgery than Dr. Rich.”
Targeting the Pharmacy
DOD’s pharmacy system employees, who can influence which drugs are selected at base pharmacies, took more than 400 trips at a cost of more than $400,000 from medical industry sources, according to the Center’s analysis. Drug companies paid more than $115,000 for travel to popular destinations, including Las Vegas, Orlando, San Diego, New York City, New Orleans, Rome, and Paris.
Not all pharmacy employees can influence drug purchases directly and some lack even indirect authority, but chief pharmacists of on-base pharmacies have the option of serving on the board responsible for selecting drugs the facility will sell. Moreover, the pharmaceutical industry’s presence is felt more broadly, says Dr. Adriane Fugh-Berman of Georgetown University School of Medicine. Fugh-Berman, an authority on industry influence on medicine, notes that pharmacists often seek advice from one another and that drug companies can create a “net of influence” around the drug selection process.
These companies are not trying to curry favor, according to Szabo, the former chief of Pharmacy Service at the U.S. Army Health Clinic at Schofield Barracks. Szabo, while sitting on the base’s drug-selection committee, took trips paid for by Cardinal Health and GlaxoSmithKline, but he insists the only motivation behind the paid travel is altruism. “They feel it’s goodwill,” Szabo says. “I’ve never favored Glaxo products, and Cardinal Health deals in durable things, not drugs, so they would have no benefit by selecting me.”
Conflicts of Interest
Studies in the Journal of the American Medical Association and CHEST, a medical specialty journal, have found a link between perks bestowed on doctors and an increased likelihood that physicians, usually unknowingly, would prescribe a company’s drugs. Academic studies like these spurred a recent movement to regulate industry gifts to medical professionals. Since 2003, the American Medical Association’s guidelines have prohibited physicians from accepting subsidies from industry “directly or indirectly to pay for the costs of travel, lodging, or other personal expenses of physicians attending conferences or meetings.” Senators Chuck Grassley, Republican of Iowa, and Herb Kohl, Democrat of Wisconsin, proposed legislation this year that would require drug companies and medical device manufacturers to publicly disclose all gifts given to doctors valued at more than $100.
Such concerns have prompted Admiral Thomas McGinnis, chief of the Pharmaceutical Operations Directorate for DOD’s military health care program, to prohibit his direct staff from going on company-paid trips. Still, McGinnis is puzzled at why the medical industry would spend so much doling out free trips to military pharmacists. “I don’t really know what the hook is, what their advantage is,” McGinnis says. “I don’t see the reason why firms would do that.”
Ethics experts say the reason is obvious — gifts from drug companies affect the decisions of pharmacists. “They pay for them because it works,” asserts Thomas Murray, president of the Hastings Center, a nonpartisan bioethics research institute. “Trust me, their marketing departments are paying very close attention to cost benefit analysis for these kinds of gifts.”
DOD drug spending may merit that kind of attention. From fiscal year 2000 to fiscal year 2006 the Pentagon’s prescription drug spending more than tripled from $1.6 billion to $6.2 billion, according to a Government Accountability Office report issued in April 2008. Spending hit $6.8 billion on drugs in 2008, says Admiral McGinnis, and the GAO expects DOD pharmaceutical spending to reach $15 billion by 2015. McGinnis estimates that DOD spending on drugs purchased at on-base pharmacies alone accounts for about two percent of all drug sales nationwide.
Despite banning his staff from accepting drug-company sponsored travel, McGinnis nonetheless allows DOD pharmacists to attend continuing education programs and other events paid for by drug companies, a practice common for pharmacists in civilian practice. These trips save DOD money and are appropriate, McGinnis says, as long as the company is not promoting a drug at the event and as long as participants reveal their ties with industry.
But Dr. Fugh-Berman, the principal investigator of PharmedOut, a project to educate physicians about the influence of pharmaceutical companies on prescribing patterns, argues that allowing medical professionals to take industry-paid trips may actually cost more in the long run. The costs of purchasing more expensive or unnecessary drugs, a phenomenon studies have associated with gifts to doctors, dwarf bills for the occasional continuing education conference, she says.
Expenses aside, Fugh-Berman says the ultimate problem is with allowing even the appearance of doctors and others owing a debt to medical drug and device companies. “Industry and medicine are not on the same side,” Fugh-Berman insists. “Doctors and other health care professionals are supposed to represent the best interests of their patients, and industry is supposed to represent the best interests of its shareholders. These are not the same.”
Researcher Laura Cheek and Staff Writer Jillian Olsen contributed to this report. Pentagon Travel is a joint project by the Center for Public Integrity and the Medill School of Journalism at Northwestern University.
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