Drug companies in Europe, faced with declining sales and a shortage of new products, appear to be making ground in their attempt to enlist a major new ally in their struggle for profits - the patient.
Sales soared in the US after companies were allowed to advertise their prescription medicines on TV and radio and in magazines and newspapers. Patients in America began demanding more drugs and specific, expensive brand-name drugs from their doctors. Now the firms want to target the UK in the same way, and are strongly challenging a ban on direct consumer advertising in the EU.
This has been tried before. In 2002, there was an attempt to persuade the European parliament to allow companies to launch "disease awareness campaigns", which critics believed would encourage people to believe they were sick and lead to demand for new drugs from doctors.
Then, as now, industry was aligned with certain patient groups which it funds.
In 2002, Merck Sharp and Dohme paid for a 30-page supplement distributed with the New Statesman which included full-page adverts backing changes to advertising rules. One was signed by 15 European patient groups coordinated by Rodney Elgie, president of the mental health organisation GAMIAN-Europe.
"What we were advocating ... was that one should be free within the necessary checks and balances to secure information from any valid authorised source," said Mr Elgie.
He rejected criticism from some consumer organisations that patients' groups are biased by accepting drug company funding: "They employ a perverse logic that because patient groups accept pharmaceutical funding they are automatically in the pockets of drug companies."
Mr Elgie pointed to the funding behind one of the major consumer groups, HAI - Health Action International. "It has consistently received around 65% of its funding each year from the Dutch government ... Yet this is no way affects their judgment on a host of issues. So far as I am aware, no patient group is so beholden to one drug company to such an extent."
The European parliament refused to weaken the advertising rules five years ago. But the industry, with the backing of drug company-funded patient groups and a few vocal MEPs, has again succeeded in persuading the European commission that the rules need reform, and it is now discussing how this could be done.
Nobody uses the word "advertising". All the talk is of allowing pharmaceutical companies to give information direct to patients.
However, it is the trade arm of the commission - not the health arm - that is involved in the discussion and looking at ways to allow companies access to patients. It has set up a pharmaceutical forum to come up with proposals, chaired by commissioners Gunter Verheugen and Markos Kyprianou.
Critics complain of a lack of transparency and that the membership of the working group on information to patients has not been made public.
Only two patient groups have been included; one of them receives substantial funding from the pharmaceutical industry. A coalition of critics, the Medicines in Europe Forum, which was launched in 2002 and comprises consumer groups, the International Society of Drug Bulletins (which assess medicines independently of the industry) and European health insurers, wrote to the commissioners last week expressing their dismay.
Information
In their letter, they deplored the fact "that since its inception the pharmaceutical forum has operated with an almost total lack of transparency" and warned that it was not in drug companies' interests to provide full and unbiased information to patients.
Recent scandals, such as the heart deaths linked to the arthritis painkiller Vioxx, "are potent reminders that pharmaceutical companies often minimise or even fail to disclose adverse effects", they said.
"In a fiercely competitive marketplace, pharmaceutical manufacturers naturally have an obligation to their shareholders to realise profits from sales. They must therefore promote their own drugs rather than other preventative or treatment options. As a result, pharmaceutical companies are utterly incapable of providing the reliable comparative information needed by patients."
Mr Elgie disagreed. Drug companies were a legitimate source of information about their products, he said, and insisted the consumer was capable of recognising promotional advertising, whether of medicines or of washing powder.
Where the money comes from
Leading patient groups, and the companies that support them:
European Patients Forum
The EPF was set up after the European commission said it would prefer to deal with one pan-European organisation representing patients. The EPF's first president, from launch in January 2003 until 2005, was Rodney Elgie, from the mental health organisation GAMIAN-Europe, who is a central figure in the evolution of patient groups linked to the pharmaceutical industry in Europe. The EPF was strongly criticised for a lack of transparency by the campaigning group Health Action International in July 2005. "European patients are ill-served by a group whose close links to the pharmaceutical industry amount to an enormous risk of conflict of interest," said Jeremy Smith, author of the HAI report. The EPF at the time did not publish details of its funding. Now it does, and virtually its entire income comes from drug companies.
International Alliance of Patient Organisations
IAPO was set up in 1999 by 38 patient groups with funds from the Pharmaceutical Partners for Better Healthcare, a collaboration of some 40 drug companies. Pharmaceutical Partners closed down that same year, throwing IAPO into serious financial difficulties. Pfizer stepped in with a grant in 2002 to help IAPO develop a strategy for the future. A variety of individual companies have supported it since then. In 2006, drug companies contributed $250,554 (£127,000) out of a total income of $278,755. In 2006, GSK, Pfizer, Medtronic and Novartis were the biggest sponsors, each providing more than $50,000 a year.
GAMIAN-Europe
The Global Alliance of Mental Illness Advocacy Networks was founded by the drug company Bristol Myers Squibb in March 1997, bringing together 12 organisations including Depression Alliance from the UK. GAMIAN-Europe, registered in Belgium, does not detail its funding on its website, apart from acknowledging drug company grants for specific projects. It told the Guardian that nearly half (45%) of its €234,000 (£160,000) income in 2006 came from Eli Lilly, manufacturers of Prozac. Other antidepressant makers also contributed. Lundbeck sponsorship was 26% of the group's income, Pfizer 11%, GlaxoSmithKline 6% and Wyeth 1%. Just 2% came from membership subscriptions.
Alzheimer Europe
A member of the European Patients Forum and an umbrella body for national Alzheimer's associations. Over a third of Alzheimer Europe's income (37%) came from the pharmaceutical industry in 2005. The biggest payments were from Lundbeck (€51,683 - £35,347), Janssen-Cilag (€40,000) and Pfizer (€39,230). The Alzheimer's Society in the UK accepts far less from drug companies - donations amounted to less than 1% of income in the financial year 2005-06.
