Examples such as these demonstrate what the World Health Organisation (WHO) describes as `an inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of providers and the public to select and use drugs in the most rational way'. The pharmaceutical industry is a powerful economic force. Its annual sales ofUS$256 billion in 1994 came to more than the gross national product of all the countries in sub-Saharan Africa, excluding South Africa, and more than the total health expenditure of all developing countries and the former socialist economies of Europe put together.

This industry is the main source of information about drugs, and much of that information takes the form of promotion. In fact, drug companies spend about twice as much on promoting their products as they do on research. Dr Joel Lexchin, President of the Medical Lobby for Appropriate Marketing (MaLAM), says that the promotion expenditure of developing countries is often 30 per cent of sales. And the money doesn't simply go on advertising or product brochures that are the most visible elements. Providing health workers with handy reminders such as pens, prescription pads, computers and calculators is standard procedure. Performing favours and building `friendships' is even more important.

`Face-to-face promotion of drugs is the industry's majormarketing approach and is probably the most difficult to monitor and control,' says Professor C H Shashindran of the department of pharmacology at India's at Jawaharlal Institute of Medical Medication. `By encouraging personal relationships to develop, favours, gifts become hard to refuse,' adds AnneLoes van Staa, a medical anthropologist in the Philippines. `The acceptance of a gift invokes a debt of gratitude in the recipient, ensuring that the debt will eventually be paid. This is the key to success in pharmaceutical marketing.'

But the fact is that this can lead to irrational drug use. The more reliant doctors are on commercial sources of information, the less appropriately they prescribe. And, when doctors write down the wrong drug name on their prescription form the patient's health is jeopardised and his money wasted. Dr Raymond Mossop, former head of Community Medicine at the University of Zimbabwe, describes, one old lady who had been prescribed 14 different items. `Seven were completely useless,they were prescribed to counteract the effects of other drugs. It was not until she was taken off all medication that she regained her health,' he says. But it's not just health at stake. In fact inappropriate drug promotion is one of the factors contributing to the rising costs of healthcare, according to David Kessler, former Commissioner of the US Food and Drug Administration (FDA). And, in India, where `rampant' abuse of antibiotics has led to a doubling of consumption between 1986 and 1994, such a trend leads to drug resistance as well as wasted money.

Yet, for all these concerns, it is an uphill battle to keep medical education free of commercial bias and bring drug promotion under control. "The potential financial rewards for violative promotional activities are great, and the risk of serious sanctions, minimal,' says Mary Pendergast, Deputy Commissioner of America's FDA. If it's difficult to police America's marketing machine, that is nothing compared with those developing countries which have nopharmaceutical regulatory system at all.WHO has suggested a set of model guidelines called Ethical Criteria for Medicinal Drug Promotion. Its main message is that governments and health authorities should set the policies for drug use, not the pharmaceutical industry. However, a recent study carried out in Thailand, Australia, Vietnam, Laos, Sri Lanka and Indonesia found inadequate regulation of promotion by governments and little awareness of any criteria, regulations, or codes among health workers.

Companies claim that they can self-regulate. But Dr Andrew Herxheimer, co-ordinator of the International Society of Drug Bulletins, says: `Industry codes are much more show than substance. The same companies repeat their transgressions again and again. For many years, the pharmaceutical industry has cultivated a cosy relationship with health workers by suggesting that both parties were partners in public health. The evidence is now clear that this is an unhealthy partnership. Both the public and health workersneed to immunise themselves against the persuasive efforts of the industry to promote drugs, not health.