Karina

Institutional Corruption in the Pharmaceutical Industry
By: Karina Wisniewski

For: Mr. Toole
Date: May 8th, 2015
Preface
The pharmaceutical industry is a necessity to the survival and well-being of humans; it is
one of the most innovative accomplishments of civilization. The actions of the pharmaceutical
industry are meant to generate prosperity for the people in a nation. However, the industry
attracts the association of institutions seeking economic affluence and power. This results in the
presence of corruption. Corruption causes an industry to take on a more commercial and venal
role in the world. The presence of institutional corruption in the pharmaceutical industry causes
skews, distortions and misrepresentations in the knowledge of healthcare professionals and the
public. Corruption occurs through lobbying and political contributions, industry pressure and
commercializing the role of physicians (Light, Lexchin & Darrow, 2013). In the pharmaceutical
industry, institutional corruption results in a multitude of dangerous consequences for patients.
Firstly, institutional corruption in the pharmaceutical industry is present through lobbying
and political contributions. Lobbyists in the pharmaceutical industry are individuals who seek to
influence the government; in this case drug development companies seek market protection.
Primarily this regards the high cost and risk involved with the research and development (R&D)
of new drugs. Lobbyists encourage the government to authorize "billions in taxpayer
contributions to support R&D" (Light et al., 2013). However, only 1.3% of R&D dollars are
actually spent on the research of new drugs (Light et al., 2013). This indicates that companies are
using market protections to develop new but therapeutically unimproved drugs. Companies are
able to charge excessive prices for these "new" drugs based on brand name and newness. An
American and Canadian study found that 80% of the increases in drug costs go to paying for
minor variations in drugs rather than important advancements (Light et al., 2013). Therefore,
new drugs entering the market are simply variations of preexisting drugs and show no signs of
higher effectivity for consumers.
Secondly, institutional corruption is present through industry pressure. Drug testing
companies (such as Health Canada or the FDA) are underfunded by government; as a result
approving drugs is a long process which can take up to 30 months. It was decided that turning to
industry funding would shorten drug review times and create incentives for innovations in drug
development. However, it was "found that each 10-month reduction in review time [...] resulted
in an 18.1-percent increase in serious adverse reactions, a 10.9-percent increase in
hospitalizations, and a 7.2-percent increase in deaths" (Light et al., 2013). Reduction in review
time leads to limitations in a company's ability to approve drugs for use. As deadlines approach
and funding from industries rises, the amount of impetuous and bias drug approvals increases.
Thirdly, institutional corruption is present through the commercialization of physicians.
Physicians control the distribution of drugs to patients. They have access to an ample amount of
drugs, but often times little information is present on how to prescribe these drugs and their
effects. Development companies provide bias information and evidence to physicians to
encourage them to promote their products. As well, "Most doctors take money or gifts from drug
companies in one way or another. Many are paid consultants, speakers at company-sponsored
meetings, ghost-authors of papers written by drug companies or their agents, and ostensible
'researchers' whose contribution often consists merely of putting their patients on a drug"
(Angell, 2009). Drug companies provide incentives for physicians to promote the use of their
medications despite the lack of evidence of safety and effectiveness. This commercializes the
role of doctors and undermines their position as independent and trusted advisors to patients.
Ultimately, there are many issues in the practices of the pharmaceutical industry and
these result in dangerous consequences for the general public. Primarily, the safety and
effectiveness of new drugs is not a priority for marketing companies. Drugs are tested alongside
a placebo, although this violates international ethical standards and does not provide accurate
information about the drug (Light et al., 2013). Companies exploit their responsibilities by
failing to ensure sufficient testing, censoring serious adverse drug reactions (ADRs) and
inadequately guarding the public from harmful side effects. In fact, in "the past 35 years, very
few drugs created represent any true advancement in drug therapy" (Mercola, 2013). And of all
new drugs on the market in the past decade "only 8 percent offered some advantages and nearly
twice that many15.6 percentwere judged to be more harmful than beneficial" (Light et al.,
2013). As mentioned before, drug companies provide limited funding into the R&D of new
drugs. As a result, in the US:
4.7 percent of hospital admissions were due to serious reactions from prescription drugs
that had been appropriately prescribed and used. [...] 2.1 percent of in-hospital patients
who received correctly prescribed medications experienced a serious ADR, [...] Of all
hospitalized patients, 0.32 percent died due to ADRs, which means that an estimated
128,000 hospitalized patients died annually matching stroke as the 4th leading cause of
death. (Light et al., 2013)
ADRs and deaths occurring outside of hospitals would noticeably increase these totals. Drug
production industries provide evidence about their products with skews, distortions and
misrepresentations. They have a powerful influence on physicians to promote the use of their
products and consumers to use their products, by withholding negative data. Therefore,
institutional corruption in the pharmaceutical industry provides prosperity to "big pharma" or
drug development companies, while threatening the health and well-being of humanity.
"It is simply no longer possible to believe much of the clinical research that is published, or to
rely on the judgment of trusted physicians or authoritative medical guidelines"
(Angell, 2009)
Summary of Research Methods

This paper was researched through various sources. The primary search engines used
include Google, Google Scholar, and ProQuest. Information was found on scholastic websites
such as Encyclopedia Britannica, CNBC, PBS, BBC, The Globe and Mail, The Washington Post,
The Guardian and many more. Numerous websites regarding health and wellness were explored
including: the Harvard Center of Ethics and the New England Journal of Medicine. Multiple
articles and works published on these websites by professors and health care professionals were
used. The websites of international organizations were also frequented. Additionally, there was
one video of a university lecture and two books referenced throughout the paper.
Background
The purpose of the pharmaceutical industry is to provide a quality of care to patients and
to improve their length and quality of life. More specifically, it works to diagnose prophylaxis,
relieve pain and suffering, provide treatment and if possible cure diseases. This is completed
through the research, discovery and development of drugs and medical equipment. The modern
pharmaceutical industry derives from "the amalgamation of modern biology, synthetic organic
chemistry, and American entrepreneurship" (Rang, 2006). As a result of evolving research
methods and growing knowledge, the pharmaceutical industry has been able to make a
significant advancement in the understanding of many diseases in the twenty-first century. The
modern era of medicine is thought to originate from the nineteenth century; however,
pharmaceutics have been in practice since the dawn of human existence.
Originally diseases were thought to be the creation of deities and supernatural forces. As
a result, many methods of healing were through incantation and prayer. In the Ebers papyrus
(1550 B.C.) the ancient Egyptians describe more than 700 medicinal methodologies that deliver
therapeutic effects through spiritual healing. Various ancient civilizations develop their own
systems for practicing medicine. In a majority of civilizations, common people were able to
provide healthcare and it was not strictly designated to physicians. The oldest records of
medicine involve medicinal preparations made from plants, animals, or minerals; they are of the
early Chinese, Hindu, and Mediterranean civilizations. These civilizations recognize the
importance of using the right variety and age of botanicals in making drugs. Many plant-derived
medications and ancient healing techniques are still in use in modern times.
The sixteenth and seventeenth century saw the increasing presence of science in medical
practices. The first pharmacopoeia (a book describing drugs, chemicals and medicinal properties)
appears in 1546 (Dailey, 2015). It contains a collective list of known drugs and directions for
making pharmaceutical preparations. Previous to this medications vary in concentration and
constituents. Pharmacopoeias became mandatory national documents. Another advance in
science was initiated by a Swiss chemist, Paracelsus. He employed the use of chemistry away
from alchemy and into the preparation of medicine. Additionally, the seventeenth century marks
the emergence of pharmacy as a distinct entity. It is mandate that only educated and trained
pharmacists can make or sell medical preparations. This ensures that the professionalism and
scientific basis of the profession is maintained.
The nineteenth and twentieth century saw tremendous improvements in the knowledge
and development of new drugs; these centuries are referred to as the basis of modern
pharmaceutics. The focus in these eras is on research and gaining understanding about drugs and
their chemical properties. This is done through the isolation and synthesizing of compounds from
plants for the first time. Isolation allows accurate doses of drugs to be administered, removes
toxic elements due to impurities and provides knowledge of chemical structures. This new
knowledge results in the creation of anti-infective agents in the form of non-toxic anesthetics,
vaccines and antiseptics. Also in these centuries, the importance of hormones and vitamins is
discovered. Therefore, these centuries mark the expansion of physical medications and
supplements.
The end of the twentieth century and the beginning of the twenty-first century do not
display many changes in the practices of pharmaceutics; however, they do display a continuously
growing knowledge. The amount of deaths from infectious disease decreases significantly, and
numerous new diseases are unveiled. Including cardiovascular disease, cancer, and stroke, which
remain leading causes of death today. As with any disease, there is extensive research required to
provide treatment and if possible, cures. However, technology promises a positive future for the
pharmaceutical industry. It allows great advancements in drug administration and the
development and production of new drugs at a much higher rate than previously.
Alternatively, another basis of modern health care comes from Hippocrates, a Greek
physician. The Hippocratic Oath is one of the oldest binding documents in history (late fifth
century B.C.); its principles provide an invaluable moral guide held sacred by doctors to this day:
treat the sick to the best of ones ability, preserve patient privacy, teach the secrets of medicine
to the next generation, and so on (Tyson, 2001). Nearly 100 percent of graduating medicalschool students swear to some form of the oath as it has remained in Western Civilization as an
expression of ideal conduct for the physician (Tyson, 2001). However, the document has been
modernized several times and its nature is very controversial. Many physicians have come to feel
that the oath is inadequate in the realities of a medical world that has witnessed huge scientific,
economic, political, and social changes, a world of legalized abortion, physician-assisted suicide,
and pestilences unheard of in Hippocrates' time (Tyson, 2001). Evolving times cause
deterioration in the meanings of the oath. Physicians stray from the moral guidelines, which
weakens the effectiveness of the modern pharmaceutical industry.
As with the growth of any industry there are a number of factors which are able to shape
its function and success. A highly predominant factor is institutional corruption. "Institutional
corruption is an institutions deviation from a baseline of integrity" (Light et al., 2013). Health
care systems are founded on the moral principles of the Hippocratic Oath (that physicians are
obliged to provide the best possible medical care). Any deviation from these principals results in
corruption. According to the video Institutional Corruption, it does not refer to the breaking of
laws or rules in an institution, but rather "a certain kind of influence, [...], that has a certain
effect" (2009). Therefore, corruption is able to effect and change the purpose and practices of an
industry. This is present through the influence, independence and responsibility of a variety of
factors. Institutional corruption gains predominance in the modern pharmaceutical industry and
results in a weakened effectiveness and a weakened public trust of the industry (Mercola, 2013).
Firstly, institutional corruption is present through influence. By definition, influence is "a
person or thing that affects someone or something in an important way" (Merriam-Webster,
2015). Influence can be environmental, social, political, physical or many more; the factors
affecting it are diverse and can simply be identified as the economy of influence. In the case of
pharmaceutical corruption, the economy of influence comes from a company or privatized group
in order to affect a weaker industry. Influence is "used by others to achieve the deviation
identified. The most common of such influences is money" (Lessig, 2013). A common form of
influence is wealth and power. The goal of influence is to impose ideologies and effect the
decisions and reason of an existing industry.
Secondly, institutional corruption is present through independence. In this case
independence does not represent the notion of being separate or singular, but rather the concept
of not being dependent upon others. Thomas Jefferson explained Dependence begets
subservience and venality, suffocates the germ of virtue, and prepares fit tools for the designs of
ambition (Jefferson, 2015). This explains that having dependence on something causes one to
be vulnerable. It causes one to have a higher enthusiasm to obey, follow, and do dishonest things
for profit. As well, the idea of non-dependence or independence does not have to represent a full
detachment from others. It can also refer to having the right dependence and having reliable
support with equivalent industrial powers. Therefore, having improper dependences allows an
industry to be corrupted and to willingly change their practices, decisions and reasoning.
The final factor affecting institutional corruption is responsibility. By definition
responsibility is "the state of being the person who caused something to happen" (MerriamWebster, 2015). Responsibility is a personal article; it is assigned to an individual or group. It is
a common belief that the one responsible for an incident is also the only one able to fix the
incident. However, this is often the person who cannot change or reform. In a industrial setting,
the object given responsibility is the source of corruption. On the other hand, those not given
responsibility unwillingly accept what is happening. They are the ones who are able to create
change, however do not feel capable. In this case, the object being corrupted is the bystander.
This kind of division of responsibility in an industry allows corruption to occur.
Institutional corruption gains predominance in the modern pharmaceutical industry
through drug development companies. The corruption from "Drug companies [is] [...] in large
part responsible for the decimation of the very core of medical science" (Mercola, 2013). Drug
companies have made the pharmaceutical industry into a marketing and manufacturing company
and has a multitude of effects . In recent years, the industry has seen a small number of
clinically superior drugs, [but] sales and profits have soared as [a result of] successful marketing
persuad[ing] physicians to prescribe [] much more costly new products that are at best
therapeutically equivalent to established drugs (Light et al,. 2013). New drugs being sold show
little advancement in medical effectiveness over existing drugs. However, drug companies have
many tactics to gain approval to market their new medications: they stage trials to minimize
harms, withhold negative evidence (adverse side effects), publish the same positive data multiple
times (under different guises), and fund trial companies. After approval, companies promote
their medication to physicians for prescription. These practices in the pharmaceutical industry in
modern time all result in an increasing wealth and power, but a decrease in adequate drug safety
and effectiveness.
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Expert: Marcia Angell

The topic of pharmaceutical corruption is a very controversial issue in the world today.
Information regarding this issue is hidden away from the view of the public and as a result,
society is often unaware of the existence of this issue. However, certain individuals work to
spread awareness of such controversial issues and make the public more attentive; Marcia Angell
is one of these individuals. She dedicates her life to becoming part of the pharmaceutical industry
and upon discovering the corruption within it she works to relay the truth to the public. She says
My most fundamental belief, is that one should follow the evidence wherever it leads. Marcia
Angell is a significant contributor to research about the immorality in health care practices and
their consequences for the public.
Marcia Angell, born April 20, 1939, is a physician and author from Knoxville,
Tennessee. She has an extensive educational background in science. She completed
undergraduate studies in chemistry and mathematics at James Madison University (in Virginia);
she then spent a year studying microbiology in Frankfurt, Germany. She received her M.D. from
Boston University School of Medicine in 1967. As well, Angell is a board-certified pathologist
and has training in internal medicine and anatomic pathology. She frequently contributes to
medical journals and is a member of several associations and committees of health. Angell
served as Editor-in-Chief for the New England Journal of Medicine in 1999 and was the first
woman do to so until resigning from her position in 2000 to pursue writing. Additionally, in
1997 she received the honor of being one of Time's twenty-five most influential Americans for
that year.
Currently, Angell is a senior lecturer in the department of global health and social
medicine at Harvard Medical School in Boston, Massachusetts. She devotes her life to
researching, writing and speaking on a range of popular media topics incorporating medical
ethics, health policy, the nature of medical evidence, the interface of medicine and the law, and
end-of-life healthcare. She says I'm not sure any individual can make much of a difference over
the long run, but like most people, I try. I have done that mainly through writing about various
aspects of medicine that I believe should be changed or reformed (Angell).
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In her researches, Angell explores the controversy in modern medical establishments

(such as the Food and Drug Administration, FDA), health care systems, alternative medicine and
the pharmaceutical industry in general. She believes that:
Health care is a need; it's not a commodity, and it should be distributed according to
need. If you're very sick, you should have a lot of it. If you're not sick, you shouldn't have
a lot of it. [...] [There] is a fundamental mistake in the way [a nation] looks at health care;
[...] market ideology is what has made the health care system so dreadful, [...] it does
what markets are supposed to do. It expands. [...] And it distributes a good according to
the ability to pay. (Angell)
Angell expresses that the health care system has taken on a commercial role in the world. She
believes that the pharmaceutical industry functions as a marketing company through the
development and distribution of medication and health services. She believes that pharmaceutical
goods are distributed based on ones ability to pay for them. As a result, the pharmaceutical
industry becomes corrupted and strays from its moral principles of practice.
Angell writes and publishes multiple articles for Harvard, The New England Journal of
Medicine, the Canadian Medical Association journal and many more regarding the corruption in
the pharmaceutical industry. As well, she has written a book titled The Truth about the Drug
Companies: How They Deceive Us and What to Do about It. Angells work highlights the faults
in the function of the pharmaceutical industry, as she says it is:
now being exposed as something far different from its image. Instead of being an engine
of innovation, it is a vast marketing machine. Instead of being a free market success
story, it lives off government-funded research and monopoly rights. Yet this industry
occupies an essential role in the [] health care system, and it performs a valuable
function, if not in discovering important new drugs at least in developing them and
bringing them to market. (Angell, 2004)
As a member of the pharmaceutical industry for several years, Angell understands how the
health care system works. She works hard to expose it for its true image and to reveal the fraud
within it. Angell does this in order to make the public more knowledgeable about the harmful
effects of drugs, inflated prices and false advertising. Ultimately, Angell makes the public more
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critical towards the information they are being fed by big companies. The pharmaceutical
industry is clearly due for reform and Angells book contains several different ideas about
possible solutions. She explains two in particular depth.
Firstly, we need to get the industry to focus on discovering truly innovative drugs
instead of turning out me-too drugs (and spending billions of dollars to promote them as though
they were miracles) (Angell, 2004). New drugs on the market are commonly only variations of
preexisting drugs. Companies see successful and popular drugs on the market and decide that
they also want a part of this profit; therefore they release the same drug under a different brand
name and patent, i.e. me-too drugs. These drugs get on market as a result of insufficient drug
testing and approval. Consequently, it is this kind of practice that motivates industries to work
solely for profit as opposed to the benefit of humanity. If drugs were approved based on their
innovativeness and improvement from existing drugs, then the drugs currently on market would
be safer and more effective. The focus of companies would shift away from simply creating
more goods and into creating better goods; therefore, an improvement in public health.
Secondly, an important reform would be to require drug companies to open their books.
Drug companies reveal very little about the most crucial aspects of their business (Angell,
2004). The whole pharmaceutical industry is very obscure and does not release a lot of
information to the general public. Humanity knows next to nothing about how much drug
companies spend or what they spend it on. Pharmaceutics receives billions in government
funding for drug R&D, however there is no information about what this money is spent on.
Additionally and more importantly than suspicious money spending, drug companies conceal
information about their products. Companies do not release the results of clinical trials, evidence
of adverse reactions or negative information. The pharmaceutical industry only releases
information which is favorable of their medications. If industries were more open to the public,
then they would be less likely to commit immoral acts. Money in the pharmaceutical industry
would be spent much more effectively, and medications on the market would be guaranteed safe
(or adverse reactions would be present for public knowledge).
Ultimately, these were only two of the reforms as suggested by Angell, and there are
many more in her published works, books and journals. Angell has a comprehensive medical
education and training. She understands the functions of the healthcare system and has devoted
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her life to researching, writing and speaking about the injustices behind it. To improve the
pharmaceutical industry and bring it back to its moral purpose is a very long and difficult process
and has to do with breaking the dependence of the medical profession on the industry and with
the inappropriate control drug companies have over the evaluation of their own products. The
sort of thoroughgoing changes required will take government action, which in turn will require
strong public pressure. It will be tough (Angell, 2004). However, Angell believes that citizens
should know what is really going on. Contrary to the industrys public relations, they dont get
what they pay for. The fact is that this industry is taking us for a ride, and there will be no real
reform without an aroused and determined public to make it happen (Angell, 2004).
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Expert: Bibliography
Angell, M. (2004, 7 15). The Truth About the Drug Companies. Retrieved 3 5, 2015, from The
New York Review of Books: http://www.nybooks.com/articles/archives/2004/jul/15/thetruth-about-the-drug-companies/?pagination=false
Angell, M. (2004). The Truth About the Drug Companies: How They Deceive Us and What to
Do About It. New York: Random House Trade Paperbacks.
Angell, M. (2007, 2 26). Taking back the FDA. Retrieved 3 5, 2015, from Boston.com:
http://www.boston.com/yourlife/health/diseases/articles/2007/02/26/taking_back_the_fda
/
Angell, M. (2009, 1 15). Drug Companies & Doctors: A Story of Corruption. Retrieved 3 5,
2015, from The New York Review of Books :
http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-storyof-corruption/?pagination=false
Angell, M. (n.d.). Healthcare Crisis. Retrieved 3 5, 2015, from Are We In a Healthcare Crisis?:
http://www.pbs.org/healthcarecrisis/Exprts_intrvw/m_angell.htm
Dr. Marcia Angell. (2015). Retrieved 3 5, 2015, from Changing the Face of Medicine :
http://www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_10.html
Marcia Angell. (2015, 1). Retrieved 3 5, 2015, from The New York Review of Books:
http://www.nybooks.com/contributors/marcia-angell/
TIME's 25 Most Influential Americans. (1997, 4 27). Retrieved 3 5, 2015, from Time:
http://content.time.com/time/magazine/article/0,9171,986206-15,00.html
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Role of Control
The pharmaceutical industry is its own entity and plays an important role in the world
today. The industry consists of many smaller internal sections, this including
researchers/scholars, developers, trial administrators, marketers and health care professionals
(physicians). There are also a number of external factors which affect the function of the
pharmaceutical industry. However, the group which has the largest role of control in the
corruption of the industry is the drug development companies. Drug development companies are
essentially the heart of the pharmaceutical industry, however they work in conjunction with all of
the other groups; researchers create drugs, administrators approve drugs, developers mass
produce the drugs, marketers advertise and promote the drugs and health care professionals
distribute and prescribe the drugs. Essentially, the group making a profit from this process is the
drug development companies. Their function becomes about producing as many drugs in a short
amount of time as possible in order to yield the highest profit. "Drug companies are [...] in large
part responsible for the decimation of the very core of medical science" (Mercola, 2013) and this
results in the deterioration of all aspects of the pharmaceutical industry.
The role of control in the pharmaceutical industry should be given to researchers and
educated scholars. Researchers do not work for profit, their only fiduciary responsibility is to
patients. The mission of medical schools [] is to educate the next generation of physicians,
carry out scientifically important research, and care for the sickest members of society. It is not
to enter into lucrative commercial alliances with the pharmaceutical industry (Angell, 2009).
The educated individuals in the pharmaceutical industry work in medical schools or hospitals;
their primary goal is to make innovative discoveries and advancements in health care. The
current role of researchers is corrupted by bias or false information and industry funding from
developers. If researchers have the role of control then the pharmaceutical industry will become
what it is meant to be, a service to the public. Through this they will follow the moral guide of
the Hippocratic Oath and provide the best health care possible to the public without seeking
profit.
Ultimately, the current role of control in the pharmaceutical industry results in corruption
which has serious effects on the public. The power is given to drug development companies; this
distribution provides little security or caution to the well-being of humans. As a result, humans
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as a society are those who should care about this issue. Corruption brings ill-practices, inflated
prices, severe adverse reactions, and falsified information about medications which are a part of
everyday life. However, because of the controversy and obscureness of this issue, many citizens
are ignorant to its prevalence. Increased awareness about the issue comes from medical experts
and researchers, such as Marcia Angell, who work to spread knowledge about the issue through
writing and speaking. A minority of the global population is aware and active against corruption
in the pharmaceutical industry, however this minority is so insignificant that knowledge about
the issue needs to be spread to others before attention can be brought to reform.
17
The Logic of Evil

The pharmaceutical industry develops and distributes medication and healthcare to the
public, hence pharmaceutics is a manufacturing and marketing company. Generally, there are
many flaws in the way tasks are carried out in the industry and this result in dangerous
consequences for consumers. Consumers may consider the role of the pharmaceutical industry in
modern times to be evil and corrupt. However, the pharmaceutical industry is a business and
businesses work in the process of making, buying, or selling goods or providing services in
exchange for money (Merriam-Webster, 2015), and this is exactly what the industry does.
Pharmaceutics research and develop products to market to the public in order to make a profit.
With this goal in mind, businesses aim to make as many products as possible in a short amount
of time in order to yield the highest conceivable profit. Often as a result of this, quality is
sacrificed for quantity and the safety, effectiveness and sincerity of a medication is jeopardized.
However, the pharmaceutical industry is a business and as a business it serves its purpose
accurately.
The role of the pharmaceutical industry in a nation is highly important as healthcare is a
public service. It impacts the social and personal aspects of an entire nation and as a result it is
often overseen by the government. Lobbyists or politicians may be representative of an industry
and work to promote their industry in the eyes of governing powers. As well, a nations
government provides high funding to aid pharmaceutics in serving the public. Despite this
funding, government and politics have a generally small influence on the practices and function
of the pharmaceutical industry. The industry is self-governing just like a business. Furthermore,
businesses need to promote their products. Drugs are promoted through the media just as any
other product. Additionally, pharmaceutical companies encourage doctors and medical
professionals to promote their products as well. Consumers are much more likely to purchase a
medication when a doctor, a trusted patient advisor, recommends it to them. As a result of this
market ideology, big companies serve their purpose and gain wealth and power. However,
through this the citizens in a nation are unwillingly subject to potentially harmful and dangerous
circumstances.
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Religion and Spirituality

The modern medical system provides treatment to an individual as a whole; this requires
attention to the biological, psychological and social aspects of health. However, a growing
realization in the medical system is that health must also embrace spiritual health.
Acknowledging spirituality in the treatment of patients allows physicians to maximize healing
and recovery, through access to mental, emotional and physical healing processes. For humans,
spirituality is the state of concerning oneself with religious beliefs and practices, thus spirituality
is interconnected with religion. Together they have the capability to influence many aspects of
modern medicine. The health care system requires a holistic approach; including care for body,
mind, social and spiritual needs "only then, as explained by Dr Ewa Kucharska, is it possible to
answer ... all [of a patient's] needs" (Necek R, 2012).
As mentioned, the modern perception of quality healthcare was created by The
Hippocratic Oath. The oath lays out an invaluable moral guideline for physicians, which is held
sacred to this day. Morality is the differentiation of actions between those which are good and
bad; all religions consist of a framework which teaches morality (Merriam-Webster, 2015).
These frameworks are outlined by various sources such as holy books, oral and written
traditions, and religious leaders. The moral aspect of medical care is deeply rooted in the
interaction between the patient and the doctor "such teleological orientation of medicine is,
according to John Paul II, made possible ... by physician's conscience, wisdom and unlimited
honesty" (Necek R, 2012). One's role as a human is to guard the dignity of another human being.
Doctors hold a position in which they are looked to as trusted advisors to patients; through this,
they are able to relieve suffering. Additionally, the suffering of man cannot be understood on
rational grounds; above all, it requires faith. Therefore, the teachings of morality which are
present in religion become the basis of quality healthcare and the context for all relations. Any
corruption in the healthcare system deviates from this basis and causes immorality which
opposes religion.
Medicine is a global market which serves to a diverse range of people. Healthcare
practices must adapt to each individual's personal characteristics and traits, primarily this
includes one's culture and religion. Religion plays a vital role in many peoples' lives as it shapes
their habits, beliefs and ultimately their entire way of living. Healthcare providers need to be
19
mindful when caring for patients of different religions; they need to acknowledge and interpret
how religious/cultural values may be pertinent to the care of a patient- "regarding personal needs,
interaction with staff, and decisions about treatment (Ehman, 2012). However, religious
traditions tend to be complex, and there are various ways which individuals/families understand
and apply the seemingly same traditions. Religion needs to be incorporated into healthcare,
although it is necessary to avoid stereotyping individuals based on religion. Acknowledging the
unique religious features of each patient personalizes their healing experience and allows healing
to occur on a physical, mental and spiritual level. Ultimately, it elevates quality of care through
creating a sense of comfort and security for patients.
The practices of the medical system are heavily influenced by the teachings of morality in
religion; however there are numerous practices conducted regularly which contradict these
teachings. An insistent issue is opposing the right to life; this is a moral principal based on the
belief that a human being has the right to live and should not be unjustly killed by another human
being. Nonetheless, this issue does not only apply to religious individuals, "The right to life is a
matter of fundamental justice which appeals to basic human sentiments." (People for Life, 2015).
In the context of healthcare, euthanasia and abortion are controversial topics which oppose the
right to life.
Often called "The Right to Choose", euthanasia or assisted suicide is the act of
intentionally ending a life in order to relieve pain and suffering. Euthanasia is death caused by a
third party, while assisted suicide is self inflicted death with means provided by a third party.
Both euthanasia and assisted suicide are gaining legality internationally; dependant on the nation,
it can warrant to physical or emotional pain. "Most religions disapprove of euthanasia. Some of
them absolutely forbid it...[they] state that those who become vulnerable through illness or
disability deserve special care and protection, and that proper end of life care is a much better
thing than euthanasia" (BBC, 2014). Medical science refers to euthanasia as dying with dignity
because it gives patients the option to legally end their suffering with a sense of dignity.
However, euthanasia may also be doctor-prescribed as a "medical treatment" (Maker & Hamlon,
2010). Religion opposes euthanasia for multiple reasons; religious individuals claim that God
forbids it and that it contradicts the right to life. Yet, the right to life claims that a human should
not be unjustly killed; euthanasia, unless corrupt, is not unjust because it occurs at the request of
20
a patient. However, the state of mind of the patient at the time of the request is impermanent and
hence the justness of euthanasia is debatable. The act of euthanasia draws a lot of controversy to
the practices of the healthcare system.
Likewise, abortion is also a controversial practice in modern healthcare. Abortion is the
intentional termination of pregnancy at the request of a patient. All religions take a strong stance
on the morality of abortion in relation to the right to life, they state that "in the light of our
conviction that the fetus has the right to live and develop as a member of the human family,... the
termination of that life by the act of man, [is] a great moral evil" (BBC, 2009). Religion and antiabortion (pro-life) advocates argue that prenatal humans are humans from the moment of
conception, and thus have the same right to life before and after birth. Alternatively, pro-abortion
advocates do not argue on the basis of the fetus, but rather on the bodily integrity of the woman
carrying the child. Abortion in the developed world is among the safest procedures in medicine
and The World Health Organization (WHO) recommends that safe and legal abortion be
available to women globally (WHO, 2015). Consequently:
People involved in an abortion are usually affected very deeply not just emotionally, but
often spiritually, as well. They often turn to their faith for ... a way to deal with their
feelings of guilt. Because abortion affects heart as well as mind, and because it involves
life and death, many people find that purely intellectual argument about it is ultimately
unsatisfying. For them it's not just a matter that concerns a human being and their
conscience, but something that concerns a human being and their God. (BBC, 2009)
Abortions have physical and spiritual consequences on all parties involved. They often leave
mothers with immense feelings of sadness, guilt and confusion which may last for years after the
procedure (Johnson, 2013). Based on the right to life, abortions in modern healthcare are
immoral and strip the rights of the fetus, while having a harmful impact on all persons involved.
Moreover, the modern healthcare system relies on physical means for the treatment of
many diseases; primarily there is heavy dependence on the use of pharmaceuticals. A common
concern posed by religious individuals is whether they should use prescription medication or rely
on their faith in God. Although medical science now has a better understanding of many diseases
"hundreds of conditions remain, about which modern medical practitioners have only partial
21
knowledge" and so religion teaches that when one "realize[s] that regardless of whether we
consult a doctor, we need to fervently pray with faith in the Almighty, not with faith in fallible
doctors" (Morris, 2007). Religious teachings do not command nor forbid the use of medicinal
treatments. A child of God should care for his or her own body; this means taking care of oneself
and appreciating the wisdom that God has given skilled researchers and physicians (Got
Questions Ministries, 2015). Hence it is entirely up for personal interpretation, as religion does
not make direct statements about the morality of medication. Nevertheless medications:
all remind us that biochemical changes in the body can radically affect the way we think
and feel... The fact that physical interventions can alter our experience in systematic and
predictable ways does not imply that all our experiences are reducible to physical causes.
But [it] is correct that perfervid faith in pharmaceuticals challenges traditional ideas about
psycho-spirituality perhaps in ways that should give us pause. (Marino, 2003).
As mentioned before, the medical system relies heavily on physical means for treatment;
however, not all diseases come from physical causes. Although pharmaceuticals show effective
in the treatment of many diseases, there are still many unknowns. Religion teaches that having
faith in God is equivalent if not superior to the healing provided by physical means.
On the other hand, entheogens are substances similar to pharmaceutical or recreational
drugs which hold religious purposes or meanings. Entheogens are to be used in strict reverence
(in a ritual) to act as divine sacraments and to facilitate transcendent experiences. Originally
called psychedelic or hallucinogens, the term entheogens was derived from the Greek meaning of
"God within" (Nelson, 2007). The term expresses a meaning of generating God or the divine
within a person. In Christianity, the bible makes reference to using substances in the terms of
healing- "no longer drink only water, but use a little wine for the sake of your stomach and your
frequent ailments" (1 Timothy 5:23). This verse refers to the use of alcohol in the treatment of
illness. However, the bible also makes reference to remaining sober from substances- "be soberminded; be watchful. Your adversary the devil prowls around like a roaring lion, seeking
someone to devour" (1 Peter 5:8). Ultimately there is much contradiction within the teachings of
religious texts. God does not make direct statements forbidding nor encouraging the use of
medication. Therefore, in religious context the appropriate use of prescription medications and
substances varies greatly and is up to personal experience and preference.
22
The consistent teaching throughout religions is the concept of morality. With the
presence of corruption in the pharmaceutical industry, there are many cases of immorality and
injustice which cause harm to patients and the general public. Within the pharmaceutical
industry, the research and development of drugs is distorted. Humans are turning away from the
idea of spiritual healing, which is a necessary part of the healing process. The ideology that
diseases (including mental) are caused only by physical means is gaining reverence. And thus,
internationally humans are developing heavy dependencies on physical means of treatment (e.g.
drugs, medications), despite the high levels of ineffectiveness, adverse reactions, and lack of
safety. A US citizen made the following statement comparing religion (in the grace of stories) to
healthcare: the medical system "had betrayed me, but not before its belief system had leached to
the very root of me, the belief that, when all is said and done, we are beyond the grace of stories,
that only chemicals can cause hurt, and thus only chemicals can cure" (Marino, 2003).
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Case Study: Serbia

Serbia, officially known as the Republic of Serbia, is a sovereign state. It is situated
between central and southeast Europe covering the Pannonian Plain and the central Balkans.
Serbia shares international borders with many countries including Hungary, Romania, Bulgaria,
Macedonia, Croatia, Bosnia, Montenegro, and Albania. The capital of Serbia is Belgrade, which
is one of the largest cities in Southeast Europe. The population of Serbia is approximately 7.2
million people. Serbia is a member of the UN, and an official candidate for membership in the
European Union, which is negotiating its EU accession. Serbia is an upper-middle class income
economy with a dominant service, industrial, and agriculture sector.
The modern Serbian healthcare system consists of primary, secondary, and tertiary care
centers. Most primary care centers provide services such as general medicine in an outpatient
setting. Larger clinics often offer more specialized services. Mental health has become of
increasing public concern in Serbia; it is the aftermath of the recent wars in Serbia. Even several
years after the end of the 1999 bombings both post-traumatic stress disorder (PTSD) and
depression have remained prevalent in Serbia. The leading cause of death in Serbia is stroke,
cardiomyopathy/ myocarditis, ischaemic heart disease, respiratory cancers, hypertensive heart
disease, and many others. The average life expectancy at birth for both males and females in
Serbia is 75 years (WHO, 2015).
In the past few decades, there have been many changes in the Serbian government and
healthcare system. These changes were set up when Serbia was a republic of Yugoslavia. During
earlier years, healthcare was free, but practically unavailable to all people. There were no fixed
prices, and as a result services were often abused. Today, reforms have mandated a basic level
of health services for all people at varying co-payments, and services not covered may be
supplemented by private insurance. Overall, the recent healthcare reforms have tried to change
the emphasis from curative to preventative care. However this concept has failed to be
implemented. Current concerns in the field of Serbian healthcare, as reported by the medical staff
providing care, are poor funding for primary care, inadequate equipment and supplies,
inadequate salaries, and inadequate continuing medical education.
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The culture of healthcare in Serbia is considered very corrupt. The nature of the
healthcare lacks education and research. Taking care of oneself is mainly practiced when a
patient is already ill versus as a preventative measure. When care is sought from healthcare
professionals such as doctors or nurses, a bribe is commonly expected. As a curative measure for
illness it is often suggested to have changes in activity level. Additionally the cause of an illness
may be linked to an improper diet, or fate. Most Serbians or former Yugoslavians feel that health
is the most important thing in life. They recognize it as wealth and strength.
Nenad Borojevi, was the former head of the Institute of Radiology and Oncology in
Belgrade, Serbia. Borojevic was a 51-year-old cancer specialist and a member of a group of ten
Serbia-based doctors and drug company officials. They were charged in 2010 with taking, or
offering, more than 500,000 euros in bribes to persuade healthcare professionals to use specific
products. In June 2010 police arrested Borojevic and four colleagues for running a criminal
conspiracy in cancer drugs from 2007 to 2009. The indictment said that the alleged scheme,
involved drug company representatives giving incentives to doctors to use their products. This
had increased sales of a number of generic chemotherapy medicines and branded cancer
medicines including Roche Holding AG's Avastin and Erbitux, made by Merck KGaA of
Germany. For Borojevic, the alleged gains were significant, specifically regarding the facts that
Serbia is a country whose GDP per capita is put at just $6,500 a year. In total, he was accused of
receiving a total of 11.2 million dinars ($138,000) in kickbacks from drug companies (Vasovic &
Hirschiller, 2012).
Officials at drugs companies AstraZeneca Plc, Sanofi SA and Actavis confirmed they
were served in July and August 2011 with criminal indictments related to allegedly improper
payments to physicians including Borojevic at his state-run institute, and said they had filed
certain procedural objections. Icelandic pharmaceutical company Actavis gave the most
expansive statement: "The allegations include bribery of state officials in order to obtain
preferential status when it comes to the sale of oncology products in Serbia" (Vasovic &
Hirschiller, 2012). All declined further comment on the proceedings. Also charged with alleged
bribery in the case were representatives of Roche, Merck KGaA and PharmaSwiss - a unit of
Canada's Valeant Pharmaceuticals International Inc - all of whom declined to comment. The
indictment against Borojevic also states that he and colleagues did a deal with an unnamed drug
25
company sales staff to develop "new therapeutic applications" using their companies' drugs, as a
way of further boosting the sales of the products.
Corruption is rife in Serbia, which is ranked 86th out of 183 countries in Berlin-based
Transparency International's corruption perceptions index. The drugs business is particularly
exposed to corruption, Transparency International says: "pharmaceuticals create vast
opportunities for graft across both rich and poor countries. Its 2011 Bribe Payers' Index ranks
pharmaceuticals and healthcare 13th out of 19 industries on probity - a lower ranking than
defense firms, though above mining and construction" (Vasovic & Hirschiller, 2012).
Temptations may increase as companies move into the developing world. IMS Health, which
analyses pharmaceutical industry trends, says 17 key emerging markets will account for around
63 percent of worldwide growth in prescription drug sales between 2010 and 2015.
In recent years, Big Pharma has contributed billions of dollars to settle scandals involving
improper promotion of medicines in the United States. Now bribes paid to foreign doctors and
other state employees are shaping up as the next major legal liability threat for the industry. A
Reuters examination of U.S. Securities and Exchange Commission (SEC) filings by the world's
top 10 drug companies has found that eight of them recently warned of potential costs related to
charges of corruption in overseas markets. One factor driving the trend is a search for new
business. Companies whose profit margins have been squeezed in the developed world are
increasingly turning to thinly regulated emerging markets for growth. At the same time, U.S. and
European governments are toughening up on bribes paid by companies overseas. The U.S.
Foreign Corrupt Practices Act and Britain's new Bribery Act, which came into effect last July,
are both targeting drugs companies and providing new impetus for the industry to clean up its
act.
Borojevic's story, some of which emerges here for the first time, is a particularly
gruesome example of what even people in the global drugs business concede is a growing
problem: bribery and corruption in emerging markets. Borojevic had been one of Serbia's most
eminent doctors, a director of the Institute for Oncology and Radiology. Borojevic was portrayed
in Serbian media as a poisoner of children, based on suggestions in the media that he had
overprescribed medications. Borojevic was released on bail in November 2011. He repeatedly
denied all the charges against him, saying he was the victim of a media witch hunt. "Nothing is
26
true from the indictment," he said in a statement in May 2011. He was due in court in five days
later to face charges brought by the public prosecutor that he had taken bribes from international
drug companies as incentives to use their products. An electronic tag was a condition of his
500,000 euro ($660,000) bail. The next day, around noon, a passer-by found Borojevic hanging
from a tree on a nylon rope five millimeters thick. Police found a suicide note in the mailbox of
his wife, from whom he was separated. It had been sent from a local post office. "I couldn't take
it anymore," it said.
27
Case Study: Nigeria

Nigeria, or officially the Federal Republic of Nigeria, is located in Western Africa.
Nigeria shares land borders with Benin, Chad, Cameroon, Niger, and the Atlantic ocean. Nigeria
is often referred to as the "Giant of Africa" due to its large population and economy. It is the
most populous country in Africa and the seventh most populous country in the world with 174
million inhabitants, growing annually. The primary religions practiced by Nigerians are Islam
and Christianity, along with a minority group practicing religions indigenous to the country.
According to the World Bank Nigeria is an emerging market power, primarily due to the
country's oil reserves which play a major role in its growing wealth and influence.
Despite Nigeria's strategic position in Africa, the health, health care, and living
conditions in the country are poor. As a result, the life expectancy at birth for males is only 53
years and for females only 55 years (WHO, 2012). The quality of Nigerian healthcare is
inadequate; it has a "lack of coordination, fragmentation of services, dearth of resources,
including drug and supplies, inadequate and decaying infrastructure, inequity in resource
distribution, and access to care and very deplorable quality of care"(Osain, 2011). Various ideas
of reform have been put forward by the Nigerian government to address the issues in the health
care system, but they have yet to be implemented at the state and local government area levels.
As well, a major problem afflicting the healthcare system in Nigeria is the lack of doctors,
nurses, and pharmacists commonly known as "brain drain". It is estimated that there are four
doctors for every 10,000 inhabitants. Highly-trained experts often leave the country for North
America and Europe in order to pursue their profession in countries with better infrastructure or
higher wages. It has been identified as one of the goals of the government to retain these
extensively trained professionals (Internations, 2015).
Health care provision in Nigeria is a concurrent responsibility of the three tiers of
government in the country: the federal, state, and local government. Firstly, the local government
manages the lowest level of the health care system. Local governments administer to the 774
local government areas (LGAs) in Nigeria. They focus on healthcare and the dispensing of
medicine. Secondly, the state government manages the middle level of the health care system.
This includes the various general hospitals. This level is the first to provide specialty services
such as diagnostic services, rehabilitation, etc. The health care in this level is provided by
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hospitals. Lastly, the federal government manages the highest level of the health care system. In
this level there is work done with voluntary and nongovernmental organizations, as well as
private practitioners. The federal government's role is mostly limited to coordinating the affairs
of the university teaching hospitals and Federal Medical Centers. Patients are provided
healthcare at local levels, and are only permitted to state or federal levels with referral.
The rapid population growth of Nigeria is not being accommodated for adequately, and
as a result the water and sanitation in Nigeria is poor. The gap between areas that have access to
water supply and sanitation and those without is growing wider. Urban areas experience greater
coverage, whereas peri-urban, semi-urban, and rural areas are experiencing stagnation or decline.
Assessing the status of Nigerias progress towards its Millennium Development Goal (MDG)
(eight-fold goal to bettering the country) targets is difficult. A lack of accurate data makes it
impossible to determine whether Nigeria is making progress to meet its MDGs targets. The
United Kingdoms Department of Foreign and International Development (DFID) classified
Nigeria as one of the four most off-track MDG countries in Africa(citation). In May 2005, the
Nigerian Minister of Water Resources said that increased spending on water programs resulted in
a huge increase in the access to safe water supply, from 35 percent in 1999 to 65 percent in 2004.
A year later, the Ministry revised its access figure upwards to 68 percent. The World Health
Organization (WHO), however, estimates that the figures are closer to 48 percent for improved
drinking water and 44 percent for improved sanitation. Regardless, Nigerias water infrastructure
has suffered from poor operation and maintenance and the very low access to improved
sanitation constitutes a serious public-health problem.
Nigeria is a developing country, and as such the most common diseases are infectious.
The diseases with the highest prevalence are Malaria, tuberculosis and other respiratory tract
infections, diarrheal diseases, and tropical diseases. Additionally, Nigeria has the second largest
amount of people living with HIV/AIDS (citation). The HIV epidemic in Nigeria varies widely
by region. In some states, the epidemic is more concentrated and driven by high-risk behaviors,
while other states have more generalized epidemics that are sustained primarily by multiple
sexual partnerships in the general population. Youth and young adults in Nigeria are particularly
vulnerable to HIV, with young women at higher risk than young men. There are many risk
factors that contribute to the spread of HIV, including prostitution, high-risk practices among
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itinerant workers, high prevalence of sexually transmitted infections (STI), clandestine high-risk
heterosexual and homosexual practices, international trafficking of women, and irregular blood
screening.
Pharmacies have existed in Nigeria since before 1957. However, these businesses were
all owned by big multinational companies like Pfizer (healthcare company that conducts R&D of
drugs). Soon after indigenous companies like Biode emerged in Nigeria in the 1980s. The
introduction of newer companies caused the pharmaceutical industry to become more
competitive. Currently, there are 86 national pharmaceutical companies in Nigeria, however they
are only able to fulfill less than 30% of the nations needs for drugs. Therefore, it is crucial for
Nigeria to have support from other nations in the development of pharmaceuticals.
Unfortunately, this has contributed to the corruption of Nigeria's national industry and caused the
introduction of products of suspicious quality to the market; such as fake and substandard drugs.
The 1996 outbreak of Bacterial (meningococcal) meningitis in Tudun Wada, Kano,
Nigeria was the most serious meningitis epidemic ever recorded in Nigeria. It took the lives of
almost 12,000 people over a six-month period, and significantly strained the countrys healthcare
system. The fatality rate, which was as high as 20% in the first weeks, demonstrated the true
severity of the outbreak. However, it eventually, decreased to 10.7%. An estimated 15 000
people died and thousands of children were permanently disabled "Meningococcal meningitis is
a bacterial infection that causes the inflammation of the tissues that cover the brain and spinal
cord. Advanced bacterial meningitis can lead to brain damage, coma and death"(2007). Survivors
can suffer long term complications, including, hearing loss, mental retardation, paralysis and
seizures. Meningitis epidemics strike impoverished countries in sub-Saharan Africa, where
crowded living conditions and dry climates contribute to the spread of disease. Nigeria was
overpopulated, filthy and the hot conditions prevailing in Kano were ideal for the spread of the
infectious disease. Meningitis occurs in seasonal cycles (between November and June) during
the dry season. The cyclical impact of the disease has earned this area of Africa the name the
Meningitis Belt (2007).
In response to the 1996 meningitis epidemic, a non-governmental organization called
Medecins Sans Frontieres (MSF) provided free emergency treatment at the government
Infectious Diseases Hospital in Kano. The Pfizer team joined the government and the MSF at the
30
government hospital in Kano. At the time Pfizer was setting up and conducting an investigative
study of Trovan or Trovafloxacin, a drug to cure meningitis. Trovan is a flouroquinolone, and
other similar drugs in the same antibiotic class had been successfully tested in children before
(Smith, 2011). The drug gained approval in 1998, however only for adult use. After reports of
liver failure began emerging the US restricted the drug to emergency adult care only. In 1999 the
European Union banned it altogether (Mercola, 2011). During the epidemic, at the Infectious
Disease Hospital (IDH) in Kano the government hospital and the MSF were using
chloramphenicol for the treatment of children, but the Pfizer team was giving children the drug
Trovan to trial. At least 200 children were recruited into the trial of the drug, although Pfizer did
not have the proper consent required from parents to use the experimental drug on their children.
According to Nigerian authorities, Pfizer's illegal actions killed 11 children and left
dozens disabled (Mercola, 2011). It is alleged that Pfizer then left before the epidemic was over.
Trovan was only a trial drug, and therefore there were many accusations the Pfizer was simply
using the epidemic in Nigeria as an opportunity to conduct clinical trials. Pfizer dismissed the
accusations, and claimed that Trovan lowered the mortality rate from meningitis to 6%, while
chloramphenicol only lowered the rate to 9.1%. Additionally, claims were made that Pfizer did
not have consent from parents or the legal right to give children Trovan. Pfizer responded that it
was invited to help fight the epidemic and that it could not obtain informed consent because of
the illiteracy in Nigeria. Pfizer also claimed that they were given permission to administer the
drug by the Nigerian authorities. However:
Pfizer never obtained authorization from the Nigerian government to give the unproven drug
to nearly 100 children and infants. Pfizer selected the patients at a field hospital in the city of
Kano, where the children had been taken to be treated for an often deadly strain of
meningitis. At the time, Doctors Without Borders was dispensing approved antibiotics at the
hospital. Pfizer's experiment was "an illegal trial of an unregistered drug," the Nigerian panel
concluded, and a "clear case of exploitation of the ignorant".(Stephens, 2006)
Many of the claims that Pfizer makes about the events of the epidemic are contradictory to the
recorded and witnessed events from the 1996 epidemic.
31
Pfizer was taken into a 15 year legal battle by the families of four of the deceased
children regarding the issue. It was not resolved until 2011. Pfizer was sued after 11 children
died as a result of Trovan/trial drug distribution. Legal action filed against the company also
alleged that some children received a dose lower than recommended, leaving them with brain
damage, paralysis or slurred speech. Pfizer argued that meningitis and not its antibiotic had led to
the deaths of 11 children and harm to dozens of others. However, the court panel concluded that
the experiment violated Nigerian law, the international Declaration of Helsinki that governs
ethical medical research and the U.N. Convention on the Rights of the Child. The parents of the
four Nigerian children have become the first winners of a legal battle against Pfizer.
Ultimately, in 2009 Pfizer reached a tentative out-of-court settlement with the Kano state
government worth $75 million. The families of four of the children each collected cheques for
$175,000 from a compensation trust fund, after submitting DNA samples to show that the dead
were their offspring. More such compensation settlements are expected to follow. A
spokesperson from Pfizer said" We are pleased that these four individuals, the first group of
qualified claimants of the Healthcare/Meningitis Trust Fund, have received compensation"
(Smith, 2011). Seemingly Pfizer carried out the court case with dignity. However, one parent
said the process was still unwavering by local factionalism.
Following the court case, "the pharmaceutical giant also agreed to sponsor health projects
in Kano as well as creating a fund of $35m to compensate those affected" (Smith, 2011).
However, this did not occur. In fact, U.S. diplomatic cables made public by WikiLeaks show that
Pfizer hired private investigators to find evidence of corruption against Nigeria's attorney
general. This was done in an effort to pressure the general to drop legal action against the
company. U.S. officials suggest that this was done because the drug company did not want to pay
to settle the court cases. Ultimately, Pfizer still believes that the distribution of the trial drug
during the epidemic of Nigeria is a good thing, they claim that "Trovan unquestionably saved
lives, and strongly disagree[...] with any suggestion that the company conducted its study in an
unethical manner" (Stephens, 2006).
The case study of the epidemic of Meningitis in Nigeria is an excellent example of the
presence of corruption in the pharmaceutical industry. This case presents two immoral issues:
the testing of a dangerous drug on children, and conducting the testing on underprivileged
32
children in a developing country, without obtaining informed consent. If the Pfizer team did
indeed leave Kano before the bacterial meningitis epidemic was significantly contained then they
were not in Nigeria on a humanitarian mission in the first place but to conduct a clinical trial.
Therefore, the drug development company Pfizer exploited their responsibility as trusted
advisors to patients by failing to ensure sufficient testing of Trovan before administration. Pfizer
censored the serious adverse drug reactions and inadequately guarded the public from harmful
side effects. It provided misrepresented positive evidence about their drug, as well as data with
skews and distortions. Overall, Pfizer researchers took advantage of the absence of a functional
ethics committee, the desperation of the affected people and the emergency situation that greatly
facilitated recruitment. Pfizer treated the situation as an opportunity to conduct a drug trial and to
increase the distribution of their product; they continuously deny any wrongdoing.
33
Case Study: Brazil

Brazil, officially known as the Federative Republic of Brazil, is the fifth largest country
in the world by geographical area and population. It is the largest country in both South and
Latin America. Brazil is bordered by the Atlantic ocean and all South American countries with
the exception of two (Ecuador and Chile). Brazil also has a vast Amazon River basin; it contains
a tropical forest which is home to a diverse range of wildlife and ecological systems. The forest
provides extensive natural resources which span over numerous protected habitats. Brazil is the
topic of significant global interest and debate regarding deforestation and environmental
protection.
The healthcare in Brazil is a constitutional right. Public healthcare is provided to all
Brazilian citizens as well as foreigners; healthcare is universal and free. The national health care
system is known as the Unified Health System (SUS). According to WHO, the life expectancy
at birth in the country is 74 years for both sexes (WHO, 2012). The life expectancy has shown
regular increase in the past decade and is expected to continue this regular increase into the
future. This is as a result of the decrease in mortality at young ages combined with increase in
longevity. Childhood and motherhood mortality rates are at considerably high levels in Brazil.
The same may be said regarding mortality due to external causes such as transportation, violence
and suicide. The most serious and leading health problems in Brazil are ischaemic heart disease,
stroke, lower respiratory infections, diabetes mellitus, interpersonal violence, hypertensive heart
disease, and road injury to name a few. Cancer in the form of respiratory cancers places ninth on
the list as a leading cause of death (WHO, 2012).
The health of the child is a central issue particularly pertinent in developing countries;
mortality rates of children in Brazil are significantly high. Several policies have been
implemented by the national government towards improving child health over the years and
these policies have seen varying results. Ultimately, they have led to a significant decrease in
child mortality, however by international standards mortality rates in Brazil are still high.
Sanitation, education, and income are the most important explanatory factors of this poor health.
Moreover, the Infant Mortality Rates (IMRs) recorded by the Brazilian government are not
accurate because the government tends to overlook IMRs in rural areas. That is due to huge
amounts of underreporting of infant mortality cases; this causes questionability in the validity
34
and cultural accuracy of published IMRs standards. Scientists stress the importance of local-level
data and ethnography in the pursuit for a lower IMR. A UNICEF report shows a rising rate of
survival for Brazilian children; out of 195 countries researched Brazil is among the top 25
countries with the best improvement in child survival rates (UNICEF).
The Unified Health System (SUS) is the national health policy of Brazil; it sets out the
principles and directives for the delivery of health care in Brazil. The national policy is based in
the Federal Constitution of 1988. The essential goals of the health sector are the overall
improvement in nationwide health and the decrease in IMRs. Additionally, the constitution
makes reference to improving the political-institutional relation in healthcare through enhancing
the operative power of the SUS. As of 2014 there are 6,706 hospitals in Brazil, over 50% of the
hospitals are found in five of the twenty-six states. Throughout the country 78% of hospitals
practice general medicine while 16% are specialized and 6% provide only outpatient care. A
large majority (close to 70% ) of health amenities in the country are privately owned. Since
1999, the ministry of public health in Brazil has been conducting a health surveillance project in
Amazonia which includes environmental and indigenous health and disease control.
Additionally, technical cooperation projects are carried out jointly with the World Bank and
UNESCO. Brazil has a 600 million dollar World Bank loan, with which efforts are being made
to improve operational infrastructure, training of human resources, and research in the
pharmaceutical industry (World Bank).
Brazil has a dynamic pharmaceutical sector with numerous government and privately
owned companies. Multinational pharmaceutical companies are investing in Brazil for marketing
and sales directed within the country. This also acts as a platform for sales exports throughout
South America. The size of Brazils pharmaceutical and medical sectors vary, but it is likely in
the range of about $25 billion annually (Korenchuk, Asner, & Witten, 2014). Brazil is among
the greatest market consumers for medicinal drugs, accounting for 3.5% of the world market.
The national access to drugs is poor, therefore, to increase the populations' access the
government offers incentives for marketing generic products. Generic products cost significantly
less than brand name products (close to 40% less). In 2000, there were fourteen industries
authorized to produce generic drugs in the country and approximately 200 various generic drugs
were being produced. In 1998, the National Drug Policy was approved with the purpose of
35
ensuring safety, efficiency, and quality of drugs. Promotion of the drugs was for rational access
and use for the public. The production of pharmaceuticals is entrusted to public laboratories.
The top of the pharmaceutical hierarchy in Brazil is the Ministry of Health. Under the
Ministry is a scientific foundation for research and development in biomedical sciences known
as Fundao Oswaldo Cruz Foundation (Fiocruz). Two noteworthy institutions reside within
Fiocruz. Firstly, the Institute of Drug Technology (Farmanguinhos) is the largest pharmaceutical
company linked to Brazils Ministry of Health. Farmanguinhos produces over one billion
different products each year to meet demands. Among the drugs produced are antibiotics, antiinflammatory, pain relievers, medicines for endemic diseases (such as malaria and tuberculosis),
antiretroviral AIDS, and drugs for cardiovascular and central nervous system. Secondly, Brazils
Immunobiological Technology Institute (Bio-Manguinhos) produces and develops
immunobiological items. This includes vaccines, laboratory reagents, diagnosis kits, and
biopharmaceuticals. It is the main immunobiological provider to the Ministry of Health. BioManguinhos is the leading exporter of human vaccines in Brazil, and contributes significantly to
the total export sales of pharmaceuticals from Brazil. Brazil also has the National Health
Surveillance Agency (Anvisa), this is an agency within the government of Brazil that is linked
to the Ministry of Health through a management contract. Anvisa is responsible for regulating,
controlling, and inspecting products and services that have the potential to pose risks to public
health. Among other things, Anvisa monitors and regulates drugs, medical devices, smoking
products, and provides technical support in the grant of patents (Sullivan, 2012).
Brazil is widely perceived as a country wrought with corruption at every level"
(Sullivan, 2012). The healthcare system has proven susceptible to improper influence by the
private sector. A significant number of international companies report that they have been
subject to requests for bribes or unofficial payments from public officials when applying for
licenses and registrations necessary to conduct business in Brazil. Brazil's constitutional health
system is run by the government represented through Federal, State, and Municipal officials.
This system involves multiple points of access to corruption risk, because it gives multiple
avenues to improper payments which have the power to influence corrupt conduct. The potential
risk areas for corruption in the medical sector range from government involvement,
manufacturing and distribution, marketing and sales, and individual officials (government
36
employees). Brazils pharmaceutical industry is subject to extensive regulation. Any

pharmaceutical firm seeking to operate in Brazil must register its products with Anvisa. Anvisa
requires that a full clinical testing be performed in Brazil, regardless whether the drug already
has FDA approval. Anvisa approval must be obtained prior to the issuance of any
pharmaceutical patent; this rule has contributed to a significant backlog of pharmaceutical patent
applications. A foreign company seeking to market a pharmaceutical product must also have a
domestic partner, given the business cultures reliance on personal relationships (Sullivan, 2012).
Pharmaceutical corruption has pertinence in Brazil nationally; however corruption is also
present on a multinational level. This form of corruption is specific to the relationship between
developed and developing countries. Billions of people across the world do not receive adequate
medical attention; diseases which have lost presence in developed countries often still mean
certain death in developing countries. According to the World Health Organization (WHO), six
million children die every year due to a lack of medical care. There is a lack of medicine and
health infrastructure, such as doctors, logistics, supply, drugstores and diagnoses in developing
countries. Neglected disease's are typical for poor countries: tropical infections and diseases hit
low-income populations. Since these diseases practically do not exist in the West anymore there
is no interest to the commercially-oriented pharmaceutical industry. There has been practically
no research in this field for the past decades. Alternatively, the markets of these countries are still
developing, therefore their economic potential is increasing. Pharmaceutical companies
specifically invest in certain research centers and programs; developing countries are the markets
of the future. In emerging markets, such as India and Brazil, increasing affluence has already led
to an increase in lifestyle diseases: diabetes, high blood pressure, as well as heart, liver and lung
diseases (Gehrke, 2012).
Neglected tropical diseases (NTDs) are a diverse group of disease, they are one group of
diseases which thrive in the poorest populations, but almost do not exist in western societies.
NTDs have distinct characteristics and result from four causative pathogens: bacteria, virus,
protozoa, and helminth. There are seventeen NTDs prioritized by WHO which are endemic in
149 countries and affect more than 1.4 billion people; this costs developing economies billions of
dollars every year. According to WHO, fifteen out of the seventeen major NTDs in the world are
present in Brazil. "The number of people affected by NTDs is more elevated in areas with greater
37
poverty. There is a direct relationship between the prevalence of these diseases and the human
development index (HDI). There is a high prevalence of NTDs in Brazil and most of them occur
in poor regions, mainly in the north and northwest of the country" (Lindoso, 2009) (see appendix
I). Malaria, Chagas' disease, leishmaniasis, schistosomiasis, dengue fever, leprosy,
onchocerciasis, and lymphatic filariasis are NTDs of the highest prevelance.
Malaria is still a major public health concern in Brazil it "is caused by the Plasmodium
species and is transmitted by bites of the female Anopheles mosquito" (Lindoso, 2009). It is
estimated that in the early 1940s around six million cases of malaria occur each year. The 1960s
mark the lowest reported cases of malaria, but from the 1960s onward Brazil underwent a rapid
settlement project in the Amazon which led to a progressive increase in reported cases. The main
mosquito vector is present in about 80% of the country, but currently the incidence of malaria in
Brazil is almost exclusively (99.8% of the cases) restricted to the region of the Amazon Basin. In
this region a number of factors favor disease transmission and impair the use of standard control
procedures. "Since a vaccine against the disease is not yet available, adequate access to
opportune diagnosis and intervention is necessary to avoid unnecessary deaths" (Malar, 2010).
However, as mentioned before the pharmaceutical industry of developed countries neglects the
industry in developing countries. Malaria along with other NTDs practically do not exist in
developed nations anymore. Therefore, to commercially-oriented pharmaceutical industries there
is no interest to provide aid in the form of healthcare, vaccines, or drugs to the developing
countries in need.
38
International Organizations
Corruption is a pertinent issue in many aspects of everyday life. The international
economic system has created conditions at a global level whereby corruption can flourish. It is
common for humans to assume that corruption is not an issue simply because it is a part of the
governing institutions to which they are accustomed. However, through corruption all elements
of a society are undermined. Among other things, the health of people is significantly affected.
There are several international pharmaceutical organizations which largely contribute to this
corruption, such as the Food and Drug Administration (FDA). Subsequently, there are also
numerous organizations which seek to provide humans with awareness of the corruption which is
occurring in their healthcare systems. Through eliminating ignorance and spreading knowledge,
these organizations provoke the notion of change in hopes of improving the health of humans on
a global scale.
The Food and Drug Administration (FDA) is the U.S. department of health and human
services. The FDA is a national organization, however there are departments of health present in
each nationality. The FDA specifically is responsible for protecting the health of the public by
assuring the safety of medical products/food/cosmetics, advancing health innovations and
providing the public with accurate information about medicine/food/cosmetics. In accord with
pharmaceutical industries, the FDA is responsible for approving new drugs for use.
Pharmaceutical industries often make large financial contributions to the FDA for reviewing its
drugs. They also fund a team of doctors and researchers to publish journals to hide the drugs
side effect and overstate its benefits. The FDA does not perform any independent scientific
research and studies and relies entirely on the information that is present by pharmaceutical
companies. As a result, few new drugs on the market show clinical benefits and "one in five
drugs approved by FDA seriously harm people, [consequently] prescription drugs are becoming
the 4th leading cause of death" (SOR, 2015). The FDA, allegedly the leader in public health and
safety, is incompetent in safe-guarding the public interest and safety. The FDA seeks affluence
and power through acting as a pawn for the pharmaceutical companies.
On the other hand, there are organizations which work to eliminate corruption in the
pharmaceutical industry. A primary contributor is The World Health Organization (WHO);
WHO is the authority for health within the United Nations. It is responsible for "providing
39
leadership on global health matters, shaping the health research agenda, setting norms and
standards, articulating evidence-based policy options, providing technical support to countries
and monitoring and assessing health trends" (WHO, 2015). In 2004, The Good Governance for
Medicine programme (GGM) was launched by WHO with the goal of preventing corruption in
health systems through promoting good governance in the pharmaceutical sector. The concept
behind the programme is that by showing national officials the strengths and weaknesses in their
pharmaceutical system, appropriate interventions can be applied. This is done in three phases
(see appendix II). Phase one consists of an assessment of the nation's susceptibility to corruption
and presenting the recommendations for action. Phase two consists of validating the results of
the assessment and defining the basic components necessary for good governance. And phase
three consists of implementing the national programme and ensuring that it becomes fully
integrated with the ministry of health. From the period of 2004-2012 the programme has grown
to include 36 countries all in differing phases of GGM (see appendix III). After this period,
WHO published a report which outlined a brief summary of their findings (Martin & Ollier,
2013).
Countries applied the GGM approach differently and with varying results. Ultimately, the
programme proved to be highly effective, however, there were weaknesses and vulnerabilities
experienced throughout the process. Firstly, it was identified that the regulation and control of
medicine promotion was most frequently susceptible to corruption. There was a wide-spread lack
of public access to information about this and the pharmaceutical sector in general (e.g. medicine
pricing, quality, suppliers). Secondly, medicine committees often had weak policy bases and
lacked operational procedures. Selection for key members of the committee lacked formality and
criteria. And lastly, in many countries the conflict of interest policies was lacking or poorly
implemented. The GGM programme experienced these struggles in each implemented country.
Regardless, they provide new knowledge to the WHO and humans about the nature of
pharmaceutical corruption. These struggles give the GGM programme the chance to improve and
expand before future re- implementation (Martin & Ollier, 2013).
Despite the weaknesses experienced by countries participating in the GGM programme,
GGM still proved to be a successful endeavor. The programme provided an opportunity to
inform countries, WHO and partners towards improving governance of the pharmaceutical
40
sector. This resulted in several benefits. The most important factor is the level of priority which
is accorded to tackling corruption as an issue; as a result where another anti-corruption program
is already implemented, GGM is able to achieve significant progress much more rapidly. Some
countries also experienced benefits from engaging with ministries and from receiving high
political support. Nonetheless, the process was strongly dependant on the unique features of each
country; specific areas already had predetermined pharmaceutical sectors while others required
strong support from WHO. This knowledgeable support from WHO was able to facilitate
progress through good practice and the essential element of financial support (Martin & Ollier,
2013).
Therefore, the GGM programme experienced both benefits and weaknesses while
implemented internationally from 2004-2012 (see appendix IV). The programme successfully
started the process of eliminating the corruption in the pharmaceutical sectors of 36 countries.
The process is long and enduring, however if continually implemented by the countries it proves
successful. The three phase methodology of the GGM programme has a considerable ease of
facilitation. The programme was able to increase international awareness for the value of
transparency and good governance in medicine. As a result, GGM demonstrated significant value
for money. The report "concluded that the GGM approach is an essential component of the next
generation of WHO action aimed at achieving universal access to affordable, quality-assured
medicines" (Martin & Ollier, 2013). Dialogue with broader health and development partners
revealed a potential interest in the wider application of the GGM approach in the future,
particularly for risk assessment and strengthening elements of the health system. WHO is a
significant contributor to raising awareness about the corruption in the pharmaceutical industry.
Since establishment in 1948, the WHO has taken on many pressing and initiative topics in global
health. In the twenty first century WHO is reforming in order to improve people's health,
increase coherence in global health and pursue organizational excellence.
Jointly by WHO and UNESCO, in 1949 The Council for International Organizations of
Medical Sciences (CIOMS) was established. The CIOMS is an international, non-governmental,
non-profit organization. The goal of the CIOMS is to facilitate and promote international
activities in the field of biomedical sciences and to maintain collaborative relations with the
United Nations and WHO. In the early 1980's, CIOMS implemented a program regarding the
41
safety requirements of drugs. The program derives from a modern society of drugs and vaccines.
It claims that society can "be assured that a responsible and committed effort is undertaken to
minimize drug-induced injury " (CIOMS, 2013). The CIOMS notes that humans must be
prepared to accept the possibility of remote risks as modern medical care and therapeutics further
progress in knowledge. Additionally, the CIOMS works to report on serious adverse drug
reactions - "including the ... standardized 'CIOMS I reporting form', international reporting of
periodic drug-safety updates, core clinical safety information on drugs, evaluation of benefit/risk
balance, current challenges of pharmacovigilance, management of safety information from
clinical trials ... and signal detection in pharmacovigilance" (CIOMS, 2013). The CIOMS brings
awareness to the flaws in the R&D of drugs in the pharmaceutical industry. The CIOMS warns
humans to be mindful that all drugs have adverse reactions. It presents information about adverse
drug reactions directly to the public; it does not hide them as big pharmaceutical companies do.
Therefore, the CIOMS in conjunction with the WHO and UNESCO bring awareness of the
realities of corruption in the pharmaceutical industry to the public.
Another international organization working for public interest in healthcare is the Drugs
for Neglected Diseases Initiative (DNDi). The DNDi "is a collaborative, patients needs-driven,
non-profit drug research and development (R&D) organization that is developing new treatments
for Neglected Diseases" (DNDi, 2015). R&D in the pharmaceutical industry is one of the largest
bases of corruption. As mentioned before, only 1.3% of R&D budgets is actually spent on the
research of new drugs (Light et al., 2013). Drug developers put limited research into their drug
development in order to avoid high spending and to make high profit. The DNDi does not work
for profit, therefore their only goal is to create drugs which show true therapeutic improvement
regardless of the cost of research and development. Additionally, the DNDi works with
"neglected diseases" such as malaria, chagas, paediatric HIV, and many others which continue to
cause significant morbidity and mortality in the developing world. The western pharmaceutical
industry creates drugs primarily for developed countries as there is no profit margins seen in
providing product to developing countries. The DNDi has the same function as pharmaceutical
industries, however the DNDi strives to provide true therapeutic advancements in the knowledge
of medicine and treatment.
42
Ultimately, there are many international organizations affiliated with the pharmaceutical
industry. However, some organizations bring corruption to the healthcare system, while others
attempt to eliminate corruption. The FDA is an example of an national organization which is
allegedly a leader in public health and safety. However, they provide a limited initiative to
conduct research and studies on new developed drugs. Therefore, while the FDA increases its
profits, it incompetently safe-guards the public. Alternatively, organizations such as the WHO,
the CIOMS and the DNDi work counter to corruption. The WHO implements projects such as
the GGM programme to raise awareness about the necessity of good governance in national
pharmaceutical sectors. The program proves highly effective in doing so and there are plans for
future growth and re-implementation in the future. The good moral intention of these
organizations provides the provocation necessary to eliminate corruption in the pharmaceutical
industry.
43
Canadian Connection
Canada has a strongly implemented health care system which works to improve the
health and wellbeing of humans nationally as well as internationally. Over the past decade the
Canadian healthcare system has shown constructive growth in response to changes within
medicine and society. However, the fundamentals of the industry remain the same- "universal
coverage for medically necessary health care services provided on the basis of need, rather than
the ability to pay" (Health Canada, 2014). Health Canada is the Federal department responsible
for maintaining and improving the health of Canadians. With the continued growth and
expansion of the health care system, the "goal is for Canada to be among the countries with the
healthiest people in the world" (Health Canada, 2014).
According to the World Health Report released by the WHO in 2000, on a global scale
Canada's healthcare system ranks thirtieth out of 190 countries, with the US ranking at thirtyseventh (Musgrove et al., 2000). The rankings are based on an index of five factors health,
health equality, responsiveness, responsiveness equality, and fair financial contribution. This was
the WHO organization's first ever analysis of world healthcare systems; it provides a sturdy
framework to examine health systems around the world. According to a 2012 study, the life
expectancy at birth in Canada is 81 years (World Bank, 2015). Alternatively, the leading cause of
death in Canada is heart disease followed by dementias, respiratory cancers, and stroke (WHO,
2015).
Canada sets national principles for the health care system through the federal legislation
of the Canada Health Act of 1984 (CHA). The health care system of Canada is publically funded
through income tax. The purpose of this is "to protect, promote and restore the physical and
mental well-being of residents of Canada and to facilitate reasonable access to health services
without financial or other barriers" (Health Canada, 2010). Canada's national health insurance
known as "Medicare" is designed to ensure that all residents have access to medically necessary
hospital and physician services. The government assures quality of care through federal
standards, but does not participate or collect any information about an individual's health; it
remains confidential between a person and their physician.
44
There are several factors of the Canadian healthcare system which require reform and a
raised public awareness. Firstly, doctors in Canada are more often self than government
employed. Self-employed doctors bill the government for the services they provide to patients.
As a result, the health system, known as "socialized" is actually "a mix of private providers
billing governments for publicly funded services" (O'Grady & Roos, 2014). Secondly, the health
care system has systems for each province and territory. The CHA outlines that health care
should be universal; however the system is determined provincially. This allows provinces to
tailor health services to the particular needs of their residents; however, it makes managing
health reforms across the country a significant challenge. Thirdly, the CHA also guarantees that
health services are paid for by the government, but there is variation in what is considered a
health service. For example, Quebecs system includes fertility treatments, while most other
provinces do not. As well, abortion services are not equally accessible across the country. Fourth,
when a physician provides an insured service they are not allowed to charge a user fee. However,
some physicians charge fees annually, for missed appointment, or for prescription refills. And
finally, the CHA does not cover prescription drugs, home or long-term care, prescription glasses
or dental care, as well there is limited coverage provided for mental health care. Canada is the
only country with a universal healthcare system that does not include coverage of prescription
medication. More than 60 percent of prescription medications are paid for privately in Canada
(O'Grady & Roos, 2014).
Canada's pharmaceutical sector is a highly innovative industry which employs over
26,000 people (see appendix V). Pharmacists are increasingly being recognized as the
medication management experts of the health care system. Given the increasing numbers of
medications, the aging population and the growing cost of pharmaceuticals, pharmacists are key
to ensuring safe, cost-effective drug therapy for Canadians. "Pharmaceutical sales in Canada
have a 2.5 percent share of the global market, making Canada the 9th largest world market"
(Industry Canada, 2015). Drug costs (research, development, marketing) account for an
increasingly large proportion of the expenditures in the Canadian health care system; they are the
second largest cost after hospitals. According to the Canadian Institute for Health Information
(CIHI), in Canada the total spending on drugs since 2001 has almost doubled to $22 billion. This
makes up 16% of the total health expenditures in Canada (Industry Canada, 2015). This is as a
result of increase in the use of newer, more costly drug products, as well as the dependence of
45
Canadians on pharmaceuticals. The top ten pharmaceutical products sold in Canada provide
treatment for arthritis, depression, cholesterol reduction and Asthma therapies (see appendix VI).
North America is home to the largest amount of pharmaceutical companies in the world.
In Canada alone there are several pharmaceutical organizations and companies; the top ten of
which account for half of the total Canadian pharmaceutical sales. These companies include
Johnson & Johnson, Pfizer and Apotex (see appendix VII). These industries are responsible for
the R&D of new drugs (with superior therapeutic benefits to existing drugs) as well as
advancements in medicine. In Canada in 1987, a new bill, Bill C-22, was passed and had a
significant effect on the national pharmaceutical industry. Bill C-22 was passed to increase the
life of patents held on drugs. This was a response to pressure from pharmaceutical companies. In
exchange for this enhanced protection companies agreed to spend the equivalent of 10 per cent
of their annual sales on R&D. According to the Patented Medicine Prices Review Board, the
investment into R&D has been consistently below 10 per cent since 2001. " Today, Canada is
one of the lowest-ranking countries in the developed world when it comes to the ratio of
pharmaceutical sales to R&D, well behind countries such as the United States, Britain, France
and Germany" (The Globe and Mail, 2012). Industry funding into R&D has been regularly
decreasing since 2001. In 2001 $1.17 billion was spent on R&D compared to just $0.75 billion in
2013 (see appendix VIII). Additionally, pharmaceutical companies are lobbying Ottawa for
further patent protections. This would provide pharmaceutical companies in Canada increased
power. As well it would bring them in line with European regulations, where many large drug
manufacturers are based.
Johnson & Johnson is the largest pharmaceutical industry in Canada and the second
largest in the world. It was founded in 1886, with the development of the "first ready-made,
ready-to-use surgical dressings"(Johnson & Johnson, 2015). Johnson & Johnson operates in
more than 60 countries and employs nearly 128, 000 people worldwide. Their international
headquarters is located in New Jersey, USA. They claim that specifically in Canada, their
"mission is to enrich the health and wellness of every Canadian" (Johnson & Johnson, 2015).
Through the marketing and selling of leading brands in Baby Care, Oral Health Care, Wound
Care, Nicotine Replacement Therapy, Skin and Hair Care, Nutritionals, Non-Prescription Drugs
and Eye Care categories.
46
However, Johnson & Johnson is known to constantly facilitate corruption and illegal
corporate behavior. On numerous occasions, they have participated in bribery and acts violating
the FDA and Health Canada. For example, Johnson & Johnson chose to use formaldehyde, a
human carcinogen, in their consumer products. Formaldehyde dramatically increases the risk of
asthma and allergies, eczema and skin disorders as well as other medical conditions; all of which
require pharmaceutical treatment. As said by Gwen Olsen, a nationally recognized author, "if
pharmaceutical companies were in the business of curing or preventing disease, they would be in
the business of putting themselves out of business" (Johnson & Toxin, 2012). There are many
occasions in which corruption can be seen in Johnson & Johnson. They are an excellent example
of a pharmaceutical company which seeks affluence and profit above all else. Their " business
model is quite simple: Poison, diagnose and treat (Johnson & Toxin, 2012).
Corruption in the Canadian pharmaceutical industry has a significant effect on residents.
Primarily, the safety and effectiveness of new drugs is not a priority for marketing companies.
Companies exploit their responsibilities in regards to the well-being of consumers by failing to
ensure sufficient testing and inadequately guarding the public from harmful side effects.
Methods of drug testing violate international ethical standards and do not provide accurate
information about the drug (Light et al., 2013). Additionally, companies use market protections
to develop new but therapeutically unimproved drugs. Unfortunately, pharmaceutical companies
hold a lot of power in Canada. It is easier said than done to declare that one person can make a
change.
Dr. Shiv Chopra, a Canadian doctor, is an example of an individual who has worked
against the government to raise awareness of faulty and dangerous practices in the health system.
He has pursued many battles against Canadian Prime Ministers and federal ministries of health
regarding the use of dangerous drugs in food. He defied governmental orders of silence and
spoke publicly to the media and in many Senate and parliamentary committees. Multiple times
courts supported Dr. Chopra and ruled against government attempts to silence him. However, the
government continuously allowed dangerous drugs and carcinogenic pesticides to enter the food
supply. Chopra is the author of a full account of how government corruption endangers the food
supply. His book outlines a model for the establishment of food safety and security throughout
the world. As one individual, Chopra gained an increase in public awareness of pharmaceutical
47
corruption; however he was not able to cause a reform in pharmaceutical practices. With
individuals like Chopra and the support of international organizations such as the WHO, CIOMS
and DNDi more and more Canadians are gaining awareness about the corruption in the
pharmaceutical industry. With this gaining awareness and public pressure, pharmaceutical
industries in Canada may one day reform to meet the public interest.
48
Solutions
The global pharmaceutical market is worth $300 billion a year, a figure which is expected
to rise systematically. The pharmaceutical industry works to meet the demands of humans
regarding advancements in health and healthcare. This is done through the development,
production, and marketing of drugs licensed for use as medications. However, with the increase
of business ideology and commercialization in the pharmaceutical industry "an inherent conflict
of interest [occurs] between the legitimate business goals of manufacturers and the social,
medical and economic needs of ... the public" (WHO, 2015). The pharmaceutical industry is a
necessity to the survival and well-being of humanity and the intention of the industry is to
increase the prosperity and well-being of humans. However, the association of institutions
seeking economic affluence and power results in the presence of corruption.
Corruption in the health care system causes the pharmaceutical industry to take on a more
commercial and venal role in the world. The presence of institutional corruption in the
pharmaceutical industry causes distortions and misrepresentations in the knowledge of healthcare
professionals and the public. Corruption occurs on many levels, including lobbying and political
contributions, industry pressure and commercializing the role of physicians. Ultimately, it has
many negative and dangerous impacts on humans. Corruption is present in many aspects of
human life; there are no set solutions to eliminate corruption as it is a human activity. However,
in order to eliminate corruption in the pharmaceutical industry, there are several options which
may show effectiveness. Firstly there are options which directly involve the industry, this
includes: requiring pharmaceutical companies to publicize their data and only improving new,
safe, and effective drugs. Alternatively there are options which are indirectly related to the
industry, this includes: educating the public, relying on international organizations and reform
programs, or the increased implementation and enforcement of anti-corruption acts.
As discussed by Marcia Angell, we need to get the industry to focus on discovering truly
innovative drugs instead of turning out me-too drugs (and spending billions of dollars to promote
them as though they were miracles) (Angell, 2004). New drugs on the market are commonly
only variations of preexisting drugs. These drugs get on market as a result of insufficient drug
testing and approval. Consequently, it is this kind of practice that motivates industries to work
solely for profit as opposed to the benefit of humanity. If drugs were approved based on their
49
innovativeness and improvement the focus of companies would shift away from simply creating
more goods and into creating better goods. Additionally, an important reform would be to
require drug companies to open their books. Drug companies reveal very little about the most
crucial aspects of their business (Angell, 2004). The whole pharmaceutical industry is very
obscure; society knows next to nothing about drug companies spending. Pharmaceutics receives
billions in government funding for drug R&D, however there is no information about what this
money is spent on. They also conceal information about their products; companies do not release
the results of clinical trials, evidence of adverse reactions or negative information. The
pharmaceutical industry only releases information which is favorable of their medications. If
industries were more open to the public, then they would be less likely to commit immoral acts.
The increased enforcement of anti-corruption acts in the healthcare system would help to
significantly lower levels of corruption. The World Health Assembly adopted, in 1988, the WHO
Ethical Criteria for Medicinal Drug Promotion, which outlined the ethical standards which all
medicinal drugs must be held. Many observers claim that these guidelines have been largely
disregarded. Similarly, the CIOMS implemented a program regarding the safety requirements of
drugs which has also been heavily disregarded. Many national laws currently in place already
contradict corruption. They forbid the presence of immoral practice and action in the
pharmaceutical industry. However, the lack of enforcement of these laws allows pharmaceutical
industries the utmost leniency. An increased enforcement of these laws and standards along with
stricter penalty for straying from the laws would force pharmaceutical industries to take more
care in having ethical and moral standards in their practice.
Alternatively, international organizations (as mentioned before) have widely contributed
to bringing awareness to the issue of corruption in the pharmaceutical industry. WHO in
particular implemented The Good Governance for Medicine programme (GGM) from 2004-2012
with the goal of preventing corruption in health systems. The programme showed effective in
reducing the presence of corruption and gave WHO the opportunity to examine global health
care systems. Unfortunately, the programme only lasted for a span of 8 years. The WHO would
now be able to create an improved version of the GGM programme based on their findings from
the original implementation. The WHO could re-implement the improved GGM programme on a
50
larger scale in order to accommodate more countries globally to participate in the process of
elimination of pharmaceutical corruption.
The act of corruption is very secretive in nature, and oftentimes corruption occurs without
public knowledge. Therefore education is the first solution to corruption. Public knowledge
about corruption is very limited; a high majority of the global population lives in ignorance to the
immorality of the healthcare system. It is commonplace to believe that the health care system has
the singular goal of providing effective and safe health care to humans. It is often said that
"education is the most powerful weapon which you can use to change the world" (Mandela).
Through raised public awareness, there would be higher global awareness to this issue. This
would result in high levels of public unrest and pressure to solve the issue; this may be shown
through antigovernment demonstrations (e.g. protests, rallies, and letters). Those who are
uneducated do not know about the process, provisions and procedures through which they can
get justice, but those who are educated can contribute to the building and development of
society. Unfortunately, there are no sources to provide this kind of education on a mass level,
and if there was, it is debatable whether governing powers would silence it.
The pharmaceutical industry holds a powerful role in the world today; it develops,
produces, and markets drugs/pharmaceuticals in order to provide a quality of care to patients. As
an industry, it has a strong influence on all aspects of daily life. The increasing presence of
institutional corruption in the pharmaceutical industry causes distortions and misrepresentations
in healthcare and the use of therapeutic drugs. Health care is a need, not a commodity. Market
ideology is a fundamental mistake which arises in healthcare. The pharmaceutical industry does
what a market is supposed to do: it distributes goods according to the ability to pay. The
pharmaceutical industry is now being exposed as something far different from its image; it is a
corrupt marketing machine. The fight against corruption is not easy; and the indifference of
society simply acts as an accomplice to the occurrence of corruption. Therefore, "citizens should
know what is really going on. Contrary to the industrys public relations, they dont get what
they pay for. The fact is that this industry is taking us for a ride, and there will be no real reform
without an aroused and determined public to make it happen (Angell, 2004).
Appendices
Appendix I. Geographic distribution of neglected tropical diseases in the world.
Appendix II. WHO model process to implement the Good Governance for Medicines
programme
51
Appendix III. List of countries and territories participating in the GGM programme
Appendix IV. Regional distribution of countries and territories in the GGM programme
52
Appendix V.
Appendix VI.
53
Appendix VII.
Appendix VIII.
54
55
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Institutional Corruption in the Pharmaceutical Industry

By: Karina Wisniewski

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Summary of Research Methods

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Expert: Marcia Angell

Institutional Corruption in the Pharmaceutical Industry

In her researches, Angell explores the controversy in modern medical establishments

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

The Logic of Evil

Institutional Corruption in the Pharmaceutical Industry

Religion and Spirituality

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Case Study: Serbia

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Case Study: Nigeria

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Case Study: Brazil

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

employees). Brazils pharmaceutical industry is subject to extensive regulation. Any

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry

Institutional Corruption in the Pharmaceutical Industry