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19  What's in a Name in Drugs?
    The Washington Post, Sunday, November 27, 1966

     As the Federal Government takes over increasing responsibility
for medical care, it is inevitable that it will embark on more 
systematic supervision of its cost factors -- such as physicians'
fees and drug prices.

     Naturally, the anxieties of the interested parties played a
significant part in their political part in their political stance
on Medicare and related welfare services.

     At the moment, several Congressmen are decrying the price
differential between "cut-rate" drugs available under generic
names and similar compounds marketed under brand names.  Laws are
being contemplated that would require drugs furnished under
Medicare to be generically named and priced.

     The drug industry will respond that its capacity to function
as a free enterprise is founded on the competition of products
differentiated by their brand names.  This differentiation is
reinforced by state laws that generally prohibit a pharmacist from
substituting any drug for one prescribed by brand.

     According to most pharmaceutical companies, the prohibition
of brand names would be tantamount to nationalizing the drug
industry -- a drastic measure that should be studied in depth
before partial steps toward it are implemented.

     To choose an arbitrary example, brand names like Miltown or
Equanil refer to the same drug, whose generic name is meprobamate.
These names are valuable properties for their owners.  The value of 
such a property has been developed by investments in advertising
and other promotion, which bear no relationship to the qualities
of the drugs, nor to the risk capital that went into the underlying
research -- risk that might properly justify the extraordinary 
profitability of the industry.

     This investment is now directed almost entirely at building
up the brand name as a proprietary asset.  This asset, as
distinguished from the product resulting from research, is merely
an image or verbal label designed to encourage reflex use in the
physician's prescription-writing.

     An advertising man, the late Pierre R. Garai, in a Johns Hopkins
Conference on "Drugs in our Society," wrote perceptively that:
  "...approximately three-quarters of a billion dollars is spent
every year by some 60 drug companies in order to reach, persuade,
cajole, pamper, outwit and sell one of American's smallest markets
-- the 180,000 physicians.  Direct mail, medical journal advertising,
paramedical publications, closed-circuit television, canned radio,
exhibits at conventions, samples, premiums, visits by detail men --
these make up the mighty promotional weaponry the drug companies
use to bombard their market.  And it is not too much to say that
perhaps no other group in the country is so insistently
sought after, chased, wooed, pressured, and downright importuned
as this small group of doctors who are the de facto wholesalers
of the ethical drug business."

     Such distortion of the drug industry from creative research
to competitive promotion is possibly a more serious fault than the
inflation of drug prices.  The advertising itself is a self-fulfilling
reflection on the dignity and critical capacity of the medical
profession.  Full color ads, ten pages long, adorned with models
posed "before" and "after" can hardly add to a doctor's scientific
insight into the utility of a drug.

     That such advertising also supports useful informational
activities in the same journals complicates but does not justify
the situation.

     Whether generic drugs can, in fact, be safely substituted
for branded products is a contentious question which may have no
universal answer.  A rule that insists on generic drugs, despite
a physician's prescription, will lead to a head-on collision with
professional judgments, and at the very least require a stringent,
continuous monitoring of the products by the Government, should it
take on this responsibility.

     In addition, formulation details -- binders, fillers, solvents
or packaging -- may, in a physician's sound judgment, alter the
efficacy of the prescription.  We then face a dilemma of policy:
whether to risk a serious upset of drug development and medical
responsibility, or to acquiesce in the use of Federal funds to
reward the promotional more than the scientific performance of
a particular company.

     It may be possible to steer between the shoals and the whirlpool.
Brand names as properties attached to individual drugs are at the
root of many of the degradations of the industry.  Medicare policy
can be issued to discourage them, by recognizing only generic names
of drugs.  The physician's discretion can still be protected by
preserving his right to prescribe a particular manufacturer, if he
wishes, as the source of a drug and short codes can be developed
to distinguish a variety of formulations.

     The discrimination that will then be demanded of the doctor
should encourage the wider use of cheaper generic forms unless the
doctor intends otherwise.  And the companies may be deflected in
their promotional efforts away from selling brand names of products
and toward the building of their institutional reputations.

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