MERCK SPENT $18.9 MIL. AND CIBA-GEIGY $15.3 MIL. SPONSORING 1988 SYMPOSIA, CRS SURVEY FINDS; ABBOTT HONORARIA WERE $5 MIL.; PFIZER SPENT $9 MIL. ON REMINDERS

Merck ($18.9 mil.) and Ciba-Geigy ($15.3 mil.) were the industry leaders in spending on symposia in 1988, according to information collected from 18 companies for Sen. Kennedy's (D-Mass.) Labor & Human Resources Committee and tabulated by the Congressional Research Service. Together the two firms accounted for almost 40% of the symposia expenditures disclosed in the Kennedy survey. Ciba says that its symposia expenditures supported a large number of events, "definitely in the thousands." The Ciba events ranged from regional meetings to small medical lectures. The Ciba expenditures are noteworthy because the company's ranking in terms of sales volume is not nearly as high as its symposia expenditures would indicate. The company's ratio of symposia costs to sales is probably among the leaders in the industry based on the 1988 figures. The 1988 figures, however, are exacerbated in Ciba's case by the major launch of Voltaren in the summer of 1987 continuing into 1988. The Congressional Research Service asked the 18 firms to provide data on marketing and promotional activities in 1988, such as symposia (conferences, meetings, lectures and the like), reminder items (pens, golf balls, etc.), honoraria (for both faculty and attendees) and prescription drug samples. Symposia expenses totaling about $85 mil. represented more than half of the promotional spending detailed by the Congressional survey (see chart, next page). In opening remarks, Kennedy noted that the combined costs of gifts, reminders and symposia "has increased from [nearly] $40 mil. a year in the 1970s to [over] $165 mil. in 1988," and called the expenses "a largely ignored additional cost to patients at a time when the price of prescription drugs is a growing concern." The $40 mil. figure is calculated in 1988 constant dollars to take into account inflationary increases. The Kennedy figures document the extent of the well-recognized increase in symposia expenditures industry-wide. "Companies that spent $5 mil. on symposia in 1974 spent $86 mil. in 1988, a seventeen-fold increase," Kennedy noted. Ciba-Geigy's symposia spending was directly criticized by one of the witnesses at the Kennedy hearing. Utah obstetrician John Nelson recounted the experiences of one of his former medical practice partners on an "all expenses paid" trip to the Caribbean. The trip was sponsored by Ciba-Geigy to promote its Estraderm transdermal estrogen patch. Nelson's colleague had declined to use the patch product until the trip, Nelson maintained. On the trip, Nelson maintained, the doctor and his wife "stayed at a first class hotel, [ate] lavishly [and went] snorkeling." His colleague told Nelson that he "had been required to attend some lectures" given by Ciba about Estraderm and was "now convinced that he should use the new drug as the drug of choice in all his patients." A second colleague had a similar experience. He received and accepted a golf trip to Monterey, California but still did not prescribe the drug afterwards. Nelson apparently came to the committee's attention through an article, "A Snorkel, a 5-Iron and A Pen," that apeared in the Aug. 8, 1990 Journal of the American Medical Association. A moderate critic of the industry practices from the home state of the ranking minority member of the Labor and Human Resources Committee, Nelson was a good find for a witness. Hatch defended symposia expenditures by differentiating them from gifts and reminders during questioning at the first day of the hearings. In an interchange with Health Research Group Director Sidney Wolfe, Hatch maintained that "the doctors that come aren't just herded in there like sheep; they don't just sit there. These are intelligent, highly educated people." In a written response to the Kennedy committee after the hearing, Roche also defended symposia. "Seminars and symposia are one of the most effective and comprehensive methods of communicating new information about prescription drugs to physicians," Roche said. Comparing symposia to Capitol Hill hearings, Roche said: "In the same way that members of Congress bring together experts for hearings or briefings to learn and ask questions about an issue or problem, medical specialty groups must convene meetings of experts or investigators to keep medical professionals adequately and fully informed." Roche also noted that "as a general rule, spouses are not invited to symposia or seminars sponsored by Hoffmann-La Roche." The company noted that Kennedy had information on one 1988 symposium when spouses were invited. Roche said that was an exception because the symposium required a commitment of four days and "since physicians would be away for this period of time, we felt it appropriate to invite spouses." The Utah obstetrician Nelson also testified about his experience with reminder items and gifts, including "Cefizox socks," (socks with the ceftizoxime logo distributed to physicians by SKF), "golf balls with a drug company logo or drug logo, rulers, pens, pencils" etc. Ciba-Geigy also spent the most on gifts of the 18 companies in the survey, giving away to physicians some $6.5 mil. in merchandise and other items in 1988. Ciba said the "biggest portion" of the $6.5 mil. was "a little over $4 mil." for the free distribution to physicians of Clinical Symposia, a journal that it publishes four or five times a year focusing on different therapeutic areas, including ones not covered by Ciba-Geigy drug therapies. Other Ciba "gifts" include "slides, books of scientific tables, anatomy posters and other pamphlets about disease states," Ciba said. The Ciba Collection of medical drawings was noted by ex-Ciba exec David Jones in the long version of his prepared testimony as an example of one of a group of "immensely useful programs with which any company would want to be associated." Abbott led the 18 firms with a 1988 outlay of $4.9 mil. for honoraria and expenses (for faculty and attendees), the survey found. The prevalence of honoraria and company sponsorship of medical education activities within hospitals was addressed by University of Washington clinical professor Frederick Fenster. "I have heard complaints," Fenster said, "that it is difficult to get faculty to put in their time teaching because of the time spent on such speaking engagements." J&J, which was criticized in a recent congressional report for allegedly paying honoraria to researchers to promote the anti-acne drug Retin A for an unapproved anti-wrinkling claim, reported that it spent $520,327 for honoraria and expenses in 1988. Company-sponsored symposia held by the 18 responding firms totaled 34,688 in 1988 as compared to 4,275 in 1976. Honoraria and expenses paid to faculty and attendees as continuing medical education symposia totaled more than $19.7 mil. Pfizer was far and away the biggest spender on reminder items in 1988, according to the Kennedy figures. The company spent $9.1 mil. for items, or almost half of Merck's expenditures on symposia. SmithKline spent $7.4 mil. While Pfizer spent heavily on reminder items, the company reported to the Congressional Research Service that it spent no money on gifts to doctors in 1988. J&J was the biggest distributor of free prescription drug samples nearly three years ago: the company reported to CRS that it gave away over 363.4 mil. samples. Wyeth-Ayerst was next, with more than 339.5 mil. samples, followed by Syntex, which distributed nearly 259 mil. drug samples. Participating in the survey were 18 firms reporting in their pre-merger configurations: Abbott, Lederle, Bristol-Myers, Burroughs Wellcome, Ciba-Geigy, Hoffmann-La Roche, Johnson & Johnson, Lilly, Merck, Merrell Dow, Norwich, Pfizer, Searle, SmithKline, Syntex, Upjohn, Warner-Lambert and Wyeth-Ayerst. Among the notable firms missing from the Senate survey were two major marketers of the 1980s: Marion and Glaxo. Chart omitted.