gested in Lynne Cohen's article "The Medical Reform Group searches for a purpose" (Can Med AssocJ 1990; 142: 1311-1312). Our principles are as much a beacon to us today as when they were set to paper in 1979. * Access of every person to high-quality, appropriate health care must be guaranteed. The health care system must be administered in a manner that precludes any monetary or other deterrent to equal care. * Health care workers, including physicians, should seek out and recognize the social, economic, occupational and environmental causes of disease and be directly involved in their eradication. * The health care system should be structured in a manner in which the equally valuable contribution of all health care workers is recognized. Both the public and health care workers should have a direct say in resource allocation and in determining the setting in which health care is provided. Since 1986, when the fight over Bill 94 was won, we have presented briefs on a number of issues consistent with our founding principles. For example, we were influential in our support of midwifery before the Ontario task force, opposed the Patent Act at the Senate committee hearings, have had continuous involvement in the Health Professions Legislation Review in Ontario and have supported freestanding, publicly funded abortion clinics. Our concerns brought out at the Lowy Commission about pharmaceutical advertising are reflected in the College of Physicians and Surgeons of Ontario's investigation into the relations between doctors and the drug industry. Currently cutbacks in federal transfer payments, the potential of the free trade agreement to open the Canadian market to US forprofit health care companies and
the tremendous pressure put on provincial governments to contain health care costs under the free trade agreement contribute toward creating a political and economic climate in which support for user fees might wax again and private insurance could erode universal access to health care and result in a two-tier system. We applaud the Ontario Medical Association's decision to drop its legal challenges to Bill 94 and the Canada Health Act, as well as its efforts to secure binding arbitration. These new directions of the association are consistent with positions that could be found in our newsletter in the early 1 980s. Those who want to stay ahead in the 1990s might want to consider subscribing to our newsletter. Donald Woodside, MD Andy Oxman, MD Philip Berger, MD Haresh Kirpalani, MD For the Medical Reform Group of Ontario PO Box 366, Stn. J Toronto, Ont. M4J 4Y8
Medicine in South Africa D _
r. Frank J.W. Timmermans' response in the June 1, 1990, issue of CMAJ (142: 1176-1177) to the comments on his article "Medicine in South Africa (1)" (ibid: 477-478) does not refute a single correction made to his inaccurate statements. Instead Timmermans chooses to obfuscate by once again indulging in factually incorrect generalities. Predictably, he also chooses to challenge me, not on the basis of fact, but with malicious innuendo. The opening paragraph in my letter stated my position quite clearly and succinctly: to respond to factually incorrect and hypo-
critical statements. This does not constitute support for the apartheid system, nor does it qualify me as "typical of . . . most white South African physicians". As a white South African who attended a nonracial, outstanding liberal university I have consistently been opposed to the government of South Africa and its policies. I have always worked for a nonracial society and practised compassionate medicine on a nonracial basis. I chose to leave South Africa for one reason: refusal to serve in the military. My dilemma is eloquently described by Rian Malan in My Traitor's Heart: "I ran because I wouldn't carry a gun for apartheid and because I wouldn't carry a gun against it." I find it particularly odious to be identified by Timmermans as a South African who "defends apartheid", and far from being ignorant of both systems I consider myself well informed. The gist of my statement regarding health care in Canada and other countries is that disparities in health care are the result of political decisions made by generations of politicians and not a result of physician conspiracy. Any Ontario or British physician would confirm that. The recent announcement by the South African government that all state medical facilities are to be opened to all races and a single department of health established should be recognized as progress. In conclusion I would like to echo the comments of Dr. Kenneth M. Leighton (ibid: 1 1721173) by asking Canadian physicians to recognize that, despite the indefensible disparities in health care in South Africa, there are significant numbers of physicians working within the country to effect meaningful change. Ostracism of these physicians will not further their efforts. I welcome any discussion that encourages posiCAN MED ASSOC J 1990; 143 (5)
369
tive change. However, using incorrect data to argue on behalf of a worthy cause will result in rejection of the entire message. Likewise, histrionic statements, in contrast to thoughtful letters such as that of Dr. John Dommisse (ibid: 1171-1172), do not contribute to change. Stuart D. Patterson, MB, ChB 204-20 Speers Rd. Oakville, Ont.
Reference 1. Malan R: Mv Traitor's Heart, Atlantic Monthly, New York, 1990
"Disinformation" from pharmaceutical company representatives n M X r. John Pye's response
(Can Med Assoc J 1990; 142: 1178) to my letter (ibid. 1177-1178) is, unfortunately, another example of "disinformation". It is understandable that Pye, director of public affairs for the Pharmaceutical Manufacturers Association of Canada (PMAC), would interpret my letter as lauding the approach taken by the PMAC to distribute accurate information to physicians. Unfortunately, rather than addressing my concern - presenting an accurate and honest comparison of prices of all brand-name and generic drugs in a particular category Pye dredges up arguments related to the costs and benefits and po-
to representatives of pharmaceutical companies. Many reputable detail people do give a full summary and cost breakdown of the various medications that they are comparing and do not hesitate to include generic equivalents. If at that point they try to impress upon the physician the therapeutic benefits of their products as opposed to others' that is certainly their prerogative. It is, however, not the physician's responsibility to support the economic basis of a drug company's investment and profit base by prescribing one product instead of another. It is most unfortunate that a spokesperson for the PMAC could not respond to my concerns directly but attempted to use my criticism as a basis for deflecting the issue away from accurate sharing of information to the economics of drug manufacturing. Michael Gordon, MD, FRCPC Medical director Baycrest Centre for Geriatric Care North York, Ont.
In her article "The Medical Reform Group searches for a purpose" (ibid. 1311-1312) Lynne Cohen mentions me as having "often railed against marketing methods employed by the pharmaceutical industry". I don't think that I rail: I would prefer "comment" or "criticize". But, whatever it is that I do, I would like to do it with regard to the exchange of letters between Dr. Gordon and Mr. Pye. Gordon was critical of a phar- Joel Lexchin, MD, CCFP (EM) 121 Walmer Rd. maceutical company representa- Toronto, Ont. tive for failing to include generic drugs in her cost comparison of alternative products. In his de- References fence of the representative Pye Manufacturers Associalikened comparing brand-name 1.Pharmaceutical tion of Canada: Brief to the Conmmisand generic drugs to comparing sion of Inquiry into the Pharmaceutical Industry, Ottawa, 1984: 108-109 apples and oranges. One of the major differences 2. Thomas M, Lexchin J: Pharmaceutical manufacturers' responsiveness to physithat Pye alleged was that brandcians' requests for information: a com-
tential quality differences between brand-name products and their generic equivalents. The issue that I addressed had nothing to do with the economics and politics of the drug manufacturing industry but dealt with the principle of accurately and fully presenting physicians name products are "front-ended" with information that is available by the "'significant and valuable 370
CAN MED ASSOC J 1990; 143 (5)
process . . . of bringing product information to the medical community". The unstated implication seemed to be that generic manufacturers do not provide much, if any, product information to doctors. PMAC has made the same claim in the past. ' A colleague and I recently studied one aspect of this issue by writing to a sample of brand-name and generic manufacturers and asking them if they were aware of a particular drug-drug interaction and if so to send us information about it. The results of our study were very interesting.2 There were no significant differences between the two types of manufacturer with regard to either the promptness of the response or the quality of the documentation provided. However, there was a dramatic difference in homogeneity between the two corporate groups. The generic companies were fairly similar in the time that they took to respond (median 11 days, extremes 6 and 16 days) and in the quality of the information that they provided. Among the brandname manufacturers there were marked differences in both of these variables. These companies had a median response time of 13 days and extremes of 6 and 27 days. Although one brand-name company provided 21 references, another was the only company to provide none at all. When Pye talks about comparing apples and oranges perhaps he should start closer to home.
parison of brand and generic companies. Soc Sci Mzed (in press)
the tremendous pressure put on provincial governments to contain health care costs under the free trade agreement contribute toward creating a political and economic climate in which support for user fees might wax again and private insurance could erode universal access to health care and result in a two-tier system. We applaud the Ontario Medical Association's decision to drop its legal challenges to Bill 94 and the Canada Health Act, as well as its efforts to secure binding arbitration. These new directions of the association are consistent with positions that could be found in our newsletter in the early 1 980s. Those who want to stay ahead in the 1990s might want to consider subscribing to our newsletter. Donald Woodside, MD Andy Oxman, MD Philip Berger, MD Haresh Kirpalani, MD For the Medical Reform Group of Ontario PO Box 366, Stn. J Toronto, Ont. M4J 4Y8
Medicine in South Africa D _
r. Frank J.W. Timmermans' response in the June 1, 1990, issue of CMAJ (142: 1176-1177) to the comments on his article "Medicine in South Africa (1)" (ibid: 477-478) does not refute a single correction made to his inaccurate statements. Instead Timmermans chooses to obfuscate by once again indulging in factually incorrect generalities. Predictably, he also chooses to challenge me, not on the basis of fact, but with malicious innuendo. The opening paragraph in my letter stated my position quite clearly and succinctly: to respond to factually incorrect and hypo-
critical statements. This does not constitute support for the apartheid system, nor does it qualify me as "typical of . . . most white South African physicians". As a white South African who attended a nonracial, outstanding liberal university I have consistently been opposed to the government of South Africa and its policies. I have always worked for a nonracial society and practised compassionate medicine on a nonracial basis. I chose to leave South Africa for one reason: refusal to serve in the military. My dilemma is eloquently described by Rian Malan in My Traitor's Heart: "I ran because I wouldn't carry a gun for apartheid and because I wouldn't carry a gun against it." I find it particularly odious to be identified by Timmermans as a South African who "defends apartheid", and far from being ignorant of both systems I consider myself well informed. The gist of my statement regarding health care in Canada and other countries is that disparities in health care are the result of political decisions made by generations of politicians and not a result of physician conspiracy. Any Ontario or British physician would confirm that. The recent announcement by the South African government that all state medical facilities are to be opened to all races and a single department of health established should be recognized as progress. In conclusion I would like to echo the comments of Dr. Kenneth M. Leighton (ibid: 1 1721173) by asking Canadian physicians to recognize that, despite the indefensible disparities in health care in South Africa, there are significant numbers of physicians working within the country to effect meaningful change. Ostracism of these physicians will not further their efforts. I welcome any discussion that encourages posiCAN MED ASSOC J 1990; 143 (5)
369
tive change. However, using incorrect data to argue on behalf of a worthy cause will result in rejection of the entire message. Likewise, histrionic statements, in contrast to thoughtful letters such as that of Dr. John Dommisse (ibid: 1171-1172), do not contribute to change. Stuart D. Patterson, MB, ChB 204-20 Speers Rd. Oakville, Ont.
Reference 1. Malan R: Mv Traitor's Heart, Atlantic Monthly, New York, 1990
"Disinformation" from pharmaceutical company representatives n M X r. John Pye's response
(Can Med Assoc J 1990; 142: 1178) to my letter (ibid. 1177-1178) is, unfortunately, another example of "disinformation". It is understandable that Pye, director of public affairs for the Pharmaceutical Manufacturers Association of Canada (PMAC), would interpret my letter as lauding the approach taken by the PMAC to distribute accurate information to physicians. Unfortunately, rather than addressing my concern - presenting an accurate and honest comparison of prices of all brand-name and generic drugs in a particular category Pye dredges up arguments related to the costs and benefits and po-
to representatives of pharmaceutical companies. Many reputable detail people do give a full summary and cost breakdown of the various medications that they are comparing and do not hesitate to include generic equivalents. If at that point they try to impress upon the physician the therapeutic benefits of their products as opposed to others' that is certainly their prerogative. It is, however, not the physician's responsibility to support the economic basis of a drug company's investment and profit base by prescribing one product instead of another. It is most unfortunate that a spokesperson for the PMAC could not respond to my concerns directly but attempted to use my criticism as a basis for deflecting the issue away from accurate sharing of information to the economics of drug manufacturing. Michael Gordon, MD, FRCPC Medical director Baycrest Centre for Geriatric Care North York, Ont.
In her article "The Medical Reform Group searches for a purpose" (ibid. 1311-1312) Lynne Cohen mentions me as having "often railed against marketing methods employed by the pharmaceutical industry". I don't think that I rail: I would prefer "comment" or "criticize". But, whatever it is that I do, I would like to do it with regard to the exchange of letters between Dr. Gordon and Mr. Pye. Gordon was critical of a phar- Joel Lexchin, MD, CCFP (EM) 121 Walmer Rd. maceutical company representa- Toronto, Ont. tive for failing to include generic drugs in her cost comparison of alternative products. In his de- References fence of the representative Pye Manufacturers Associalikened comparing brand-name 1.Pharmaceutical tion of Canada: Brief to the Conmmisand generic drugs to comparing sion of Inquiry into the Pharmaceutical Industry, Ottawa, 1984: 108-109 apples and oranges. One of the major differences 2. Thomas M, Lexchin J: Pharmaceutical manufacturers' responsiveness to physithat Pye alleged was that brandcians' requests for information: a com-
tential quality differences between brand-name products and their generic equivalents. The issue that I addressed had nothing to do with the economics and politics of the drug manufacturing industry but dealt with the principle of accurately and fully presenting physicians name products are "front-ended" with information that is available by the "'significant and valuable 370
CAN MED ASSOC J 1990; 143 (5)
process . . . of bringing product information to the medical community". The unstated implication seemed to be that generic manufacturers do not provide much, if any, product information to doctors. PMAC has made the same claim in the past. ' A colleague and I recently studied one aspect of this issue by writing to a sample of brand-name and generic manufacturers and asking them if they were aware of a particular drug-drug interaction and if so to send us information about it. The results of our study were very interesting.2 There were no significant differences between the two types of manufacturer with regard to either the promptness of the response or the quality of the documentation provided. However, there was a dramatic difference in homogeneity between the two corporate groups. The generic companies were fairly similar in the time that they took to respond (median 11 days, extremes 6 and 16 days) and in the quality of the information that they provided. Among the brandname manufacturers there were marked differences in both of these variables. These companies had a median response time of 13 days and extremes of 6 and 27 days. Although one brand-name company provided 21 references, another was the only company to provide none at all. When Pye talks about comparing apples and oranges perhaps he should start closer to home.
parison of brand and generic companies. Soc Sci Mzed (in press)
