Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Wind of Change
- John Stone (15 April 2005)
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The Dilemma of Pharma
- F C Gray Southon (15 April 2005)
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Do not ask for a sacrifice without an alternative in hand
- Mansur Ilahi (15 April 2005)
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Yes But
- Rex C Paddy (15 April 2005)
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same story everywhere!!!
- Vijayashankara. Nanjegowda (15 April 2005)
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UK compared to Indian subcontinent
- DR Ashan Gunarathne (15 April 2005)
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Hypocritical tosh - an alternative editorial
- Clifford G. Miller (16 April 2005)
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The Splinter
- B Levinson (16 April 2005)
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Re: The Splinter
- John Stone (17 April 2005)
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How right the Editor is.
- Griselda Halling (17 April 2005)
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Sense of Proportion
- Christopher G Pollock (17 April 2005)
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The UK is very lucky to have the BMJ
- Donna M Arnold (17 April 2005)
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Culture,Tardition and Social Fabric in Community influences the Corruption
- Paras K Pokharel, Ghopa, Dharan, Sunsari 56701 Nepal (17 April 2005)
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Doctors should decide whether they want to be pigs or not!
- Farokh Wadia (18 April 2005)
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Where to find truly independent medical education?
- Peter I H Parry (18 April 2005)
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Corporatocracy
- BM HEGDE (19 April 2005)
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Fewer frills, more pills
- Ann K Sullivan, on behalf of the ffmp committee (20 April 2005)
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Probity in Dealing with Industry
- Adam P Fitzpatrick (20 April 2005)
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What is the fuss about?
- Pablo Millares Martin (20 April 2005)
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Free lunches and hormone use promotions
- Ellen C G Grant (21 April 2005)
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a simple question
- marcio coelho (21 April 2005)
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Maddening Media
- Gary Parkes (21 April 2005)
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Invisible strings
- John Stone (21 April 2005)
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Re: Say No to Free Lunch (Editor’s Choice)
- Leana S. Wen, Christopher P. McCoy, 2005-2006 Legislative Affairs Director, American Medical Student Association (21 April 2005)
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A Question of Balance-Pharmaceutical Medicine as a Specialty
- David S Millson (22 April 2005)
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Re: A Question of Balance-Pharmaceutical Medicine as a Specialty
- John Stone (23 April 2005)
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Mad dogs, englishmen and sponsored midday luncheon.
- Roger N Chitty (23 April 2005)
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Pigs with insight
- ONASEGUN G OWONIKOKO, CASTLEBAR,CO MAYO,IRELAND (28 April 2005)
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Re: Re: A Question of Balance-Pharmaceutical Medicine as a Specialty
- John Stone (10 May 2005)
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Pharmaceutical Medicine as a Specialty
- Jackie Napier (10 May 2005)
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Re: Pharmaceutical Medicine as a Specialty (but if the truth will out will it make any difference)
- John Stone (10 May 2005)
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Re: Pharmaceutical Medicine as a Specialty
- Michael D Innis (11 May 2005)
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Pharmaceutical Medicine and the truth will out about hormonal contraceptives?
- Ellen C G Grant (11 May 2005)
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Unfortunately doctors and drug firm do depend on each other
- Peter KK Au-Yeung (12 May 2005)
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Re: Re: Pharmaceutical Medicine as a Specialty
- Michael D Innis (12 May 2005)
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Where are we 5 weeks on?
- John Stone (21 May 2005)
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John Stone, none London N22
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A great many people will be delighted hear the editor endorse the findings of the Health Committee and the programme of No Free Lunch in such forceful terms. Plainly, the costs - human and financial - of having a system that has run so rankly out of control must be far in excess of the apparently formidable costs of rectifying it. Governments will need to spend perhaps hundreds of millions of pounds in order to erect proper fences between themselves and the industry, but this will be far better than the alternative. It will serve the public, and it will serve the public purse. The real problem is that for some powerful people there are free lunches, and it is the rest of us who pay. On a personal level I would make a plea that we do not continue to live in the world of doublethink when it comes to the licensing and monitoring of vaccine. This is an area in which anyone and everyone who raises questions is firmly put in their place. This constitutes a grave public danger and it has got to stop. Competing interests: Parent of an autistic child |
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F C Gray Southon, Honorary Research Fellow University of Auckland, New Zealand
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While all the stories of perverted influence of the pharmaceutical industry may be true, we are left with the fact they we rely on it in a fundamental way for our ability to provide the treatments that we do, and also to develop better treatments. Further, the industry wields enormous power, because of its indepth knowledge of the health system and its practitioners, its global scope and pervasive influence. We alienate it at our peril. Instead of treating it as a pariah, we need to engage with it constructively. While this may not be easy, we need to remember that its viability depends on its public credibility. Competing interests: None declared |
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Mansur Ilahi, Consultant Geriatrics Medical Testing and Reaseach Organization , Islamabad , post code 44000
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Afternoon drug lunch hosted by the Drug companies is more than just another menu item to be rejected on the basis of calories pouring in from the wrong source. In this matter I would neither trivialize the importance of regularity of such events which only a commercial organization has the guts to execute nor dare to minimize the importance of the afternoon shrimps, salmon and host of other goodies which comparable favorably with bland NHS hospital diet for the doctors. Drug Lunch is infact the only occasion in a day where a junior doctor can, in practice talk freely with his consultant in a pleasant all things accepted down the gullet mode. Then the numerous small items of importance such as pens, disposable examination items only help in the routine working. Yes, such lunches and accompanying proximity does reduce the shock and awe of an honest doctor but if someone sticks to his BNF and happens to be a mature doctor it cannot alter prescription habits in any sustained manner. On a personal level, I now hesitate to go to drug company’s sponsored dinners outside the premises of the hospital s but that definitely deprives me of good lectures by overseas doctors as well. Result is an undereducated me and if goes on for long I shall know little medicine and fewer fellow doctors . However many younger doctors who are much more impressionable in prescribing habits do prescribe exorbitantly expensive medicines as a result of such type of commercial inspired teaching. The crux of the matter is that we cannot make the sacrifice of refusing a social cum educational event just for the sake of antagonism with commercialism unless the health bodies like NHS put aside special funds to sponsor such events for doctors which I am sure will find it’s way in press as an abuse of public funds and stopped ultimately. What can be done however is reduce the impact of such commercial inducements by better pharmacological and prescription teaching and compulsory testing of that in all membership and fellowship examinations, and disallowing drug companies to sponsor holidays for consultants without any education event tied to it. The impact of this commercial advertising is most disastrous in developing countries where non specialist doctors rely on the literature of Drug companies for their pharmacological knowledge and the consequence can include even selling of assets by parents of children to pay for such new treatments which are experimental as best. Yes, A case exists for refusal of the free lunch but only after provision of an alternative as it is not just a matter of a few dishes, rather a whole doctor culture revolves around this innocuous looking free lunch. Meanwhile Please do not ask for a non executable sacrifice in this earthly life ! Competing interests: None declared |
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Rex C Paddy, Chief Executive 27 Princes St Auckland NZ 1001
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As an ex pharmacist and ex drug rep and ex hospital manager I agree with everything that you say but it would have more credibilty if you also said that you had decided to accept no more advertising from drug companies. Until you do that you are hardly in a position to ask doctors to stop accepting payment, for services, from drug companies. Rex Paddy Competing interests: None declared |
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Vijayashankara. Nanjegowda, Professor of Pediatrics SDUMC, Kolar, India. 567103
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The story of the relationship between pharma and doctors is the same all over the world. It is like corrupt politicians and government officials. It is there for everyone to see. The national conferences in India of any professional bodies are attended by thousands of specialists, who come on a holiday, expenses fully paid by drug companies. A real mockery of the conferences. Are there no solutions? I do not any unless it comes from oneself. Competing interests: None declared |
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DR Ashan Gunarathne, SHO Medicine Hull Royal Infirmary HU3 2JZ
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I was so interested to read your article as a person who used to be a Medical representative before I entered medical college. So now I understand the both sides of it. During my UK experience I realised medical reps/pharmaceutical industry are not that influential to current practice compared to Indian subcontinent. I have seen doctors were even offered foreign trips, cars even a commission from the sales and have honesty observed doctors being victims of such deals. But I am afraid whether same situation will occur in few years in UK as well. But I think we cant blame the whole pharmaceutical industry because of unprofessional practice of few companies. I think it is high time to have some legal legislation on companies with bad ethical promotions as well as doctors who encourage it and accept it. But it will be difficult task to decide where to draw the line, as for some people sponsoring clinical meeting will be equal to allowing and publishing a advertisement in a medical journal or funding a clinical research. But in view of poor patients especially in third world countries, and to maintain professionalism among doctors something needs to be done. I think your article will be a good eye opener. Competing interests: None declared |
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Clifford G. Miller, Lawyer, graduate physicist and former university examining lecturer in law BR3 3LA
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Dear Dr Godlee, HYPOCRITICAL TOSH - AN ALTERNATIVE EDITORIAL Everything and nothing changes. The psychology of the medical profession is fascinating. No one speaks out. Then we get the occasional 'feel-good' editorial in the BMJ, Lancet and such-like spouting 'aren't we all wonderfully human, conscientious and right thinking' sorts of noises in time for the weekend. A bit like going to church on Sunday. By Monday, it is business as usual, prescribing all from the pharmaceutical goody cupboard, and feeling so much better for thinking right thoughts for a little while. Are intelligent and competent medical professionals really taken in day after day after day? You know all the symptoms and can diagnose and treat all manner of harm. Yet how much of acute and chronic harm is being caused by pharmaceuticals? Can you trust medical literature corrupted by papers which promote medical 'understanding' and 'thinking' in particular directions not a million miles away from the interests of the pharmaceutical companies that fund them. Do you sit back oblivious, or what do you do? How overtly corrupted the world of medicine has become at all levels. Read 'TeenScreen - Angel of Mercy or Pill-Pusher' by Evelyn Pringle about the US 'Teen Screen' mental 'health' screening programme. This sick programme is bizarrely being heavily promoted in the US where it needs US PR firms to tell the US public that really US adolescents are pretty much all sick. So, no more need or disease driven medicine! Just the techniques of Goebbels to get one in four teenage Americans on medication and labelled for life as mentally ill. That will really help control the populace in the criminal courts too, so, hey, a bit of a winner all round for centralised control and authority. Remember, what happens over there pretty soon happens over here - and it will also happen to the friends, family and relatives of the medical profession. But then, so, what the heck, by then after another hundred or so papers published in places like the BMJ and Lancet, with press headlines to tell everyone the soundbites, you will all believe it is true and 'proven' 'scientifically', so who cares, as long as we can get along week-to-week, have 42" plasma TV and holiday in nice places. Think about it. The list of drugs withdrawn from the market grows weekly since the publicity surrounding Seroxat and SSRIs. We do know that these ones are just the drugs that got 'caught'. How many others are there? Is there Orwellian double-think in the mind of a medical professional? Of course, as soon as someone produces a single government backed paper, it is (contrary to scientific method) revered and treated as the gospel and quoted in NHS publications and websites. My my, it was so excruciatingly embarrassing to see a Labour minister and peer, Lord Warner, jumping to the defence of the pharmaceutical industry following the recent critical Commons Select Committee report. Spin and PR - but from a Labour government - no change there then. We know drug companies produce new patented drugs to make more and more money and yet, when it comes to things like vaccines, it is taken on trust that these are 'safe' for infants when they are not. And are they all necessary for 620,000 infants in England and Wales each year? Not really, especially if there were hard fact published on the harm caused by them. There is no science to it and no one is counting the short and long-term cost to health in western countries. But no one out there is independent and scrutinising what is going on, save for those few who conscientiously give up their own time unfunded, to be rewarded with abuse and vilification for saying, 'hang on, you need to take a close look at this' but no one does - so it goes on. Have another nice day! A big Mac anyone? How about you Dr Fiona? Competing interests: Close relative with life threatening food allergy. |
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B Levinson, R&D USA
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As a memeber of a research and development team of a pharmaceutical company, I have been the focus of critism leveled at the marketing actvities of the industry in general. I wish to respond. An important question need be asked. What is a drug company? the operative word is company. Most drug companies are publically held and threfore must sell stock and maintain price share. To do this the company much show profit. Investors demand profit. Who are these investors who demand profit? Banks, funds, trusts, and individual stockholders. If all who critisize were to look carefully at their own porfolio or that of the funds he or she has invested in, one will likely find some degree of investment in the Pharmaceutical Industry. If so, then one must bear some responsibility for the drive to profit as a company is in competition with other companies for the sale of its stock. Thus, I suggest that before one ignores the free lunch, we must ask who demands it? The fault, may be our own. Competing interests: Pharmaceutical Industry |
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John Stone, none London N22
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It is interesting that B Levinson recognises that in the pharma he is serving the demands of the financial community. The people I blame are politicians, governments and professional associations of doctors like the British Medical Association and the General Medical Council for not protecting the public interest. What do they think they are there for? Competing interests: None declared |
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Griselda Halling, 3rd Year BSc Nutrition University of Westminster
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This is really does need addressing. Every morning a GP will be exposed to persuasive advertising, but only from those with a commercial interest. They are rarely exposed to research or advertising about the efficacy of non-patentable products. It is time for balance, and this can come from the doctors themselves. One measure for example could be asking non-pahrmaceutical company speakers to monthly practice lunches. Our healthcare providers must be free of conflicting interests and even subconscious bias. If the charity where I am a trustee (mainly offering dietary management of symptoms) accepted funds from pharmaceutical companies which make methylphenidate drugs for ADHD, then we would have no problems at all with fund-raising!! But we won't, and therefore we continue, on a shoe- string, to give well-researched advice on dietary measures for the disorder. Probably none of our work reaches GP's desks. However, there is an intriguing development, which might show pharmaceutical company recognition of a paradigm shift underway: Celltech (which by the way is paying the BMJ to advertise in this on-line issue) has named its Methylphenidate drug 'Equasym'. This is coincidentally very similar to, 'Equazen', a brand of pure fish oils which have received a lot of favourable publicity for treating ADHD. Competing interests: Trustee Hyperactive Children's Support Group. |
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Christopher G Pollock, Consultant in Anaesthesia and Pain Medicine Rowley HU20 3XR
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I don't give a toss about the free onion bahjees, or chicken legs or trips to exotic places by Big Pharma: I am more concerned about colleagues who cannot say no to the baubles of the state. Given the perilous condition of pension arrangements these days, staying sweet with the Landlords of Room 101 is perhaps a bigger distortion of professional judgement than a £10 picnic. The main difference between representatives of big pharma and the state,is that the former are polite, and the latter display an unbelievable degree of self-rightousness. The findings of a UK parliamentary committee are unfortunately tarnished by the fact that their prime minister is implicated in the deaths of 16,000 plus of civilians in Iraq in a war based on very dubious premises, and ...he is still there..untouched; they are themselves considerably marginalised by this very association; I will sit up and listen to them when their yard is clean, and so should you. Christopher Pollock Competing interests: State employee |
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Donna M Arnold, MOM Monroe NC 28110
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From reading the BMJ over a few short months, I can say they do put pharma ahead of peoples health, But they also allow the "small" people to respond with facts to discredit the garbage pharma is trying to sell. So for that reason I do have more respect for the BMJ then I do any other medical journal! In 1998 a study in the JAMA reported that 100,000 Americans died of a adverse reaction to medication and two million were left disabled. This was for one year! This did not include the mistake's made from prescribing the wrong medication. I'm not scared of dying from a terrorist, I'm scared of getting sick and having to go to the doctor. http://www.cnn.com/HEALTH/9804/14/drug.reaction/ If my company had this record of human fatalities I guess I would be spending million's of dollars lobbying senators for protection too! We need to keep pharma out of government for our own protection! Competing interests: Mom to a mercury poisoned child |
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Paras K Pokharel, Associate Professor ,Community Health & Epidemiology BP Koirala Institute of Health Sciences, Ghopa, Dharan, Sunsari 56701 Nepal
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Dear All It is very intresting to read all views.Pharmacutical or their representative are not only to be blamed in the scenaro.There are very important party that is social system in which we are working.Kerela differs from Bihar in many ways ,so is in Medical practice. Private University built with the money generated by huge corruption are never asked?Cobalt Unit or Palliiative centre built by Ciggaratte company are honoured by existing system.Alcohol and smoking are the only source to generate revenue for ceratin provinces, still people think in policy level. Yes why Doctor entraped by Medical Representative, look in our subcontinent any workshop,seminar or conferences are sponseredor or organized by them.More than that in the name of Health Care Industry we are going in depth to obey the Comapny Recrute us,Hospitals where we may be working are mostly profit oriented so it responsibility of doctors to keep idustry running in profit.That is the yard to measure the success or failure of his fortune. So it is only Iceberg phenomenon to look pills or powders alone.Look how medical services is ranked by common public that may be reflection in totality of the Ethics we preach and practice. Competing interests: None declared |
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Farokh Wadia, Clin Res Fellow, Orthopaedics Wrightington Hospital
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Indeed the Drug/ Device company will make every effort to influence the doctors and market their products. As far as it is taught in medical schools, Prescriptions have to be in pharmacological name of the drug and NOT IN THE PROPRIETARY NAME THE COMPANY GIVES IT.If doctors stick to this rule it would not matter what pharmacuetical company is providing the drug. Whether then the drug company would give a free lunch and whether a doctor wants to attend that is immaterial. Indeed then the drug company would have to target the medical stores or purchase dept for free lunches. The problem gets more complicated in Orthopaedics though as the device involved is highly specific and the costs (and therefore the profits) involved are pretty high. There is no easy solution to it and the issues involved here are purely moral. It is here that we need to have a high moral standard and good conscience. A recent example which I experienced was the highly successful British Hip society meeting which had no device company booths or representation and was purely scientific. Competing interests: None declared |
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Peter I H Parry, Consultant Child & Adolescent Psychiatrist Eastern CAMHS, 5 Darley Rd, Paradise South Australia 5075
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All too true. Some colleagues I know had managed 3 years with a committment to not seeing Pharma reps, the only practice in their region to do so, until one company, presumably aware of the doctors' sporting interests as well as prescribing practices, offered the group practice overseas trips to a major international match. Tonight I must confess I am attending a dinner meeting at our National Wine Centre, the first Pharma dinner meeting for me in a long time. I am genuinely interested in the topic and want the up-to-date knowledge promised in tonight's meeting. But I cannot avoid the knowledge that the venue must have something to do with my decision to attend. I will be on my skeptical guard, hoping the main speaker is as well - but in today's CME environment the sad fact is I cannot take what is said purely on trust. The problem is, as mentioned in other rapid responses, the dearth of medical education that is not related to (as my social work team director just mentioned) "snouts in the trough". I've heard (though cannot point to a reference off hand) that medical "education" courtesy Pharma companies exceeds all money spent on medical school education in Australia. Even if that is just approximately the case, clearly the world is up-side-down - though a laissez-faire capitalist would say it is ticking along just fine.. Competing interests: Member of "Healthy Skepticism" www.healthyskepticism.org |
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BM HEGDE, Retd. Vice Chancellor MANGALORE-575 004, INDIA.
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Dear Editor, It was in the year 1492 AD that Christopher Columbus left the shores of Spain in search of a new sea route to India with the hope that the world is round. Exactly 513 years later I am asking this curious question if the world is flat now after reading a recent book on the topic. The reader’s first impression is to rubbish this, as there is “scientific” proof to show that the world is round. One will, at most, agree that the world has shrunk into a global village, thanks to the new revolution in communications. Today a child sitting in Timbuktu could access something happening in San Francisco with the flick of a button! Doesn’t that make the world flat-level playing ground for everyone in the world? That is exactly what I meant by saying that the world is flat now. The world runs on a curious logic of consumerism today. Any commodity that could be sold will make the world rich. Drugs and pharmaceuticals are no exception here. Doctors today have become sellers and the patients the buyers. In this world justice is the convenience of the powerful and the rich. Injustice becomes justice. Plato expounds that philosophy very well in his The Republic-- a totally different word compared to the modern word Democracy. The question of free lunch does not arise at all. While everything else is built to last only for a short time, to increase profit for the producer, the philosophy of altruism can not exist in the pharmaceutical field. If doctors do not invent newer diseases to sell drugs they would be considered unproductive. If doctors confine themselves to treating only the sick the consumer society does not survive. Wealth is more and more consumerism. So, we have to invent newer indications for drugs by inventing newer diseases in the apparently healthy, the so called “doctor-thinks-you-have-a-disease syndromes.” The Patents Bill, recently passed by the Indian Parliament, to get a pat from the WTO, will, I hope, not make matters worse for the poor. Essential drugs will be beyond the reach of the poor, but the Govt. said in the Parliament that they will not allow that to happen. I want to believe the Minister. It might help the country, indirectly though, even if the prices went up, to contain the burgeoning population! Adverse Drug Reactions are the fourth important cause of death even in the US, according to the Institute of Medicine Report for that country (JAMA 2000; 284: 483-485). Some of those drugs kill more people than they save, anyway. May be that is the intention in the first place. In the US, according to the same IOM report, Adverse Drug Reactions (ADRs) are the fourth important cause of death following heart attacks, cancers, and hospitals and doctors’ interventions! Have the do gooders in the world read the British House of Commons Report on the maneuverings of the large Pharma. companies released this week? If one wants to get to the bottom of the real flat world one only has to read the following book, just published. This is a book on the New York Times best seller list. The blurb tells you that it is CONFESSIONS OF AN ECONOMIC HIT MAN, BY John Perkins, a former employee of an International consulting firm, published by Barrett-Koehler. He talks about the corporatocracy which would be an eye opener to all those that are interested in human welfare. Corporatocracy is a new addition to the long list of words like democracy, autocracy, plutocracy, monarchy and the other economic isms. Long live human kind on this planet bereft of all cracies except humanocracy (economic humanism). The world still is round with less than five percent of the population sitting on the top with 95% of the wealth and, the rest of the 95% poor people hanging on at the bottom without knowing where their next meal comes from. “The Mathew Law” still works in this world. He who hath shall be given. While the rich sit on the top the poorest of the poor drop down from below to the bottomless pit to perish for ever due to hunger, malnourishment and disease. Fifty years ago Gunnar Myrdal, a Swedish sociologist, coined the word “underclass” to describe the African Americans. The world in every field today tries to create an underclass. The patients today are an underclass used by the powerful to increase consumerism and their wealth. This produces the vicious non-linear feedback loops. The ability to buy wealth to buy political power is how the lobbies today run their business! Science has been proven right in that the world still is round! Yours ever, bmhegde Competing interests: None declared |
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Ann K Sullivan, Consultant Physician Chelsea and Wesminster Hospital, London SW10 9NH, on behalf of the ffmp committee
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Dear Editor, We read with interest your editorial (1) and related items on conflict of interest arising from accepting ‘hospitality’ and other promotional material from pharmaceutical companies. We were particularly concerned by the refusal of the American College of Physicians to rent a booth to ‘No Free Lunch’ (2). Luckily we appear to have a more liberal and open approach in the UK; at the combined conference of the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) we will be launching our new campaign ‘fewer frills more pills’ (www.fewerfrills.com; under construction). Not only have the organisers allowed us stand space; it’s free. This campaign is being established by clinicians and healthcare workers who are concerned not only with the potential conflict of interest issue, but also with the level of resources used in promotional and educational activities, especially given the current world wide lack of access to life saving HIV therapy. We propose, through various initiatives and working with the pharmaceutical companies, that some of the funds normally used to encourage attendance at educational events, provide promotional material and support conference attendance will be redirected to nominated charities providing drugs and support for those with HIV in resource poor countries. Although still at an early stage, company representatives approached thus far have been supportive and encouraging. The cynics will no doubt say it is good PR for the companies, and no doubt they would be right. But as long as some of the money goes to help provide the drugs they are promoting to those who can’t afford them, we consider it a ‘win-win’ result. However, have we inadvertently introduced another source of conflict of interest? Maybe if we ‘step away from the trough’ (1) it would enable others to take their turn. 1. F Godlee. Say no to the free lunch. BMJ 2005, 330:0-g 2. News in brief BMJ 2005, 330:862. Competing interests: Member of the fewer frills more pills committee. Have accepted financial support from many pharmaceutical companies to attend conferences and educational events. |
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Adam P Fitzpatrick, Consultant Cardiologist, Manchester Manor Lodge SK8 2NT
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Dear Dr Godlee, Editor BMJ, You send a strong message about the importance of probity in dealings between doctors and industry, as did you predecessor. He used pictures of doctors as pigs feeding from a trough! However, it is worth sounding a note in counter-argument. As a cardiac electrophysiologist in a tertiary centre, I use about 5- 10 drugs regularly, and I believe all of them are now off-patent. Most of my activities involve the use, or implantation, of medical devices. These have to come from industry, however, so the usual issues apply, but there are differences. Many implantable devices for the management of cardiac arrhythmias have very complex functions, and getting the best settings for care of the device, the arrhythmia, and the whole patient, is complex, and becoming more so every year. At the same time, we have a new NSF Chapter for Arrhythmias, awareness of widespread postcode variation in availability of skilled care for arrhythmias, and the need for a big increase in the skilled workforce. Who will provide this workforce expansion? The answer is existing NHS staff, many of whom are fully stretched, and have no time set aside for training others, and the device industry. Many companies invest vast sums of money in the NHS each year for teaching, training and research. Training courses for technicians, (cardiac physiologists), junior cardiology trainees, and consultant cardiologists, are a staple offering from most major companies without which workforce growth is quite impossible to imagine. Industry also fund all the major CME/CPD events on the calendar, where major breakthroughs in life-saving and life- enhancing treatments for cardiac arrhythmias have been presented, most of them funded by industry, not governments, e.g. pacemakers, implantable defibrillators, device therapy for heart failure, and curative catheter ablation. Not only do they fund these events, most of them abroad, but they handle the travel and accommodation needs of delegates. Can the NHS do this? No. The NHS study leave budget is laughable, and the NHS has no core skills other than those of employees already stretched by spiralling clinical demands. There are no professional educators within the NHS, even clinical management conferences are outsourced to professional conference organising firms at vast expense. Without CME/CPD, NHS patients will get old skills and defunct technology, and consultants will fail appraisal and revalidation. The NHS cannot provide what is needed because it has no skills to do so. I believe the problem is not the relationship with industry as outlined above, it is the fact that it is un-stated, and therefore completely open to principled or malicious questioning. More modern, mature departments that I know of have engaged industry as educators and trainers as part of their terms in procurement contracts. The level and nature of support for teaching, training, research, travel, accommodation and meetings can be stated as part of a contractual arrangement between a supplier and a procurer. Standards can be set, for example, an agreement for business class fares for consultants travelling to academic meetings on flights longer than 4 hours, (bearing in mind that ALL UK civil servants are entitled to first class travel!). Such contracts could be available on the internet, (with pricing removed if this is commercially sensitive), for other NHS bodies to access, learn from and emulate. What doctors do during their study leave should be a matter of public interest if funded by the tax-payer, but in my experience it amounts to essential professional development and education, not a series of alcohol- fuelled boondoggles. What doctors do during study leave should not be the subject of rumour and innuendo. It needs a framework that holds doctors, NHS and industry to account, and maintains standards. We badly need sophisticated contracting with industry that recognises the totality of added-value, and removes the stigma of relationships with industry that are mostly good for patients, and which the NHS fails to deliver any other way. -
Dr Adam P Fitzpatrick MD FRCP FACC
Competing interests: None declared |
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Pablo Millares Martin, GP Leeds LS12
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It is surprising to read an editorial suggesting the marketing campaigns of the pharmaceutical industries are dirty tricks. In a consumist society like ours, what company does not try to sell its products whatever the way if it is cost-effective (a favourite term by health proffesionals). We are not in medieval times when pharmacists made up the potions from different components according to the doctor's instructions on an individual basis. We are on the XXI century, where there are not only numerous possible already prepared drugs in all forms and shapes which do the same job, but even there are drugs to prevent disease and do other miracles. Whether you believe in the power of the chemical or not is another matter. Take for example the cosmetic industry, are you telling me they are not brain-washing customers with freebies -for newspaper/magazines editors, so they comment on their products-, adds everywhere and moving as much money as the pharmaceutical companies? Do doctors get influenced? Obviously, as everybody else that watchs TV ads. If there was nothing at the end of the tunnel, you would not get into it. But does it mean doctors put the drug before the patient? Allow me to disagree. As a GP, as a hospital junior doctor before, I have been in the hot spot for many reps (and probably more to come) and I know they have my records with my way of prescribing (so does the government and the local PCT, another big influence on prescribing, and more focused on cost before patient), they also write down anything I enjoy, family and other bits and pieces that could prove benefitial in twisting my predefined prescribing patterns. It is a marketing campaign, and as other industries, as politicians, they aim to sell their product, and they lie to you (just look at the current election campaign!). Influence can determine I choose one product over another in a few patients, but not that I am prescribing blindly that product on everybody whatever the prize I could have been promised/given. As a doctor, I have to choose among the different drugs available (I cannot ask lightly the chemist to make up the tablets from the chemicals I would like) and if there is more than one in the group I am required to prescribe, the choice is susceptible to be changed. Think just in the current guidelines for ischaemic heart disease management, if you need to use one beta-blocker, one statin and one ace-inhibitor or AT-II, you have to choose three drugs among 50. Which one? It is up to the personal experiences of the prescriber, the cost (main concern from PCT), the image of the tablet (selling point from the rep)... And personal experience is to me the biggest factor. No matter the pressure, if you consider yourself that a drug is not worthy, no campaign will make you change your mind. And if you are going to control the perks to doctors from pharmaceutical companies, at least you should promote the same with other professions (namely politicians, magazine editors, to name just a couple) as they influence our lives even more. Competing interests: None declared |
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Ellen C G Grant, physician and medical gynaecologist Kingston, KT2 7JU, UK
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Editor, I sympathise with doctors who are still keen to prescribe progesterones and oestrogens. 50 years of misleading results, underestimations of harm, confusions about basic mechanisms, a desire to control overpopulation, and the effects of numerous promotional free lunches and conferences, are hard to shake off. Competing interests: None declared |
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marcio coelho, pharmacology lecturer federal university of minas gerais, brazil
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It is really sad to read that the criteria a doctor rely on when choosing a drug are personal experiences, cost and the image of the tablet, and that personal experience is the biggest factor. I would like to ask a simple question: does the demonstration of clinical efficacy and safety provided by well conducted clinical studies conducted over years with thousands of patients deserve any attention ??????? If not, I do understand why the drug companies really have this absurd influence on the behavior of nearly all the doctors, dentists and pharmacists. Competing interests: None declared |
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Gary Parkes, GP The Limes Hoddesdon
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The evidence that doctors are influenced by drug reps is no longer in doubt. For this reason, as a front line GP in the UK, I never see drug reps. Five out of six of doctors in my partnership do not see drug reps. Our biggest enemy and pressure to prescribe new expensive products of the Pharmaceutical industry is the Daily Newspaper. Two recent examples of cuttings that have been brought to me are ‘the new tablet for osteoporosis with no side effects’(huh?) and the ‘patch for chronic back pain’ which turned out to be a narcotic that is already in use for terminal care. Outrageous and irresponsible reporting by newspapers is major problem. Deregulation of drug advertising and advertising to the public through the back door in the guise of news are unwelcome sources of extra pressure to prescribe. The second, maddening source of pressure to prescribe new drugs are patients who have seen Consultants privately. Having been given a drug that is restricted in some way by the PCT or by NICE, the patient then presents their case for having the same drug on the NHS as it is too expensive to pay the pharmacist the real price. Competing interests: None declared |
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John Stone, none London N22
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At this stage several doctors have written in to protest the beneficial nature of the pharmaceutical industry's relationship with the medical profession, apparently from first hand experience, but without declaring any competing interests. Perhaps the people they deceive most of all are themselves. Interestingly, Adam Fitzpatrick makes a valid point about technical support but each of his several instances is about the correct use of a device and not about pharmaceuticals. Competing interests: None declared |
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Leana S. Wen, National President-Elect, American Medical Student Association 1902 Association Drive, Reston, VA 20191, Christopher P. McCoy, 2005-2006 Legislative Affairs Director, American Medical Student Association
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EDITOR—It’s not surprising that the medical profession continues to deny that it is under the control of drug companies1—the systematic “branding” of physicians begins in the earliest stages of medical training. Medical students receive lunches, pens, and books given by drug companies throughout their clinical training, and come to expect industry freebies as an entitlement2. Required “educational” sessions for clinical students are often sponsored by drug companies. At medical conferences, we witness our colleagues and mentors queued up for the trinkets and gadgets handed out by industry – even though the policies of the sponsoring professional medical organizations proscribe such behavior3. Are ethics merely words printed in esteemed journals? How are we, the next generation of physicians, to react to the hypocrisy of those scenes? The American Medical Student Association (AMSA), an organization of over 55,000 physicians-in-training, started the PharmFree Campaign in 2002 to educate and train our members to professionally and ethically interact with drug companies4. As one of very few major medical organizations that is completely independent of pharmaceutical sponsorship and advertisements, AMSA believes that students should think critically before accepting drug company gifts, and that medical schools have a responsibility to provide formal instruction for students to assess such contacts. Perhaps these efforts are the beginning of our profession restoring its principles as one that advocates for patients, not one that can be bought by drug companies. 1 Godlee, F. Say No to Free Lunch [Editor’s Choice]. BMJ 2005; 330, (16 April).2 Bellin M; McCarthy S; Drevlow L; Pierach C. Medical students’ exposure to pharmaceutical industry marketing: a survey at one U.S. medical school. Acad Med 2004; 79 (11):1041-5. 3 Chren MM; Landefeld S; Murray T. Doctors, drug companies, and gifts. JAMA 1989; 262: 3448-51. 4 AMSA’s PharmFree Campaign. http://www.amsa.org/prof/ pharmfree.cfm (accessed 20 Apr 2005). Competing interests: None declared |
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David S Millson, GP Principal & Visiting Professor of Medicines Management (Keele University) Leek Health Centre, Fountain Street, Leek ST13 6JB
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Whilst I would not disagree with the sentiments expressed by Dr Ferner in his article concerning "The influence of big Pharma", it is a pity that he does not comment on recent developments in Pharmaceutical Physician Specialist accreditation. This is a turning point in recognising the role of the Pharmaceutical Physician as a powerful influence to counter the marketing departments of big Pharma.Over the last ten years (supported by the Royal College of Physicians) a working party of physicians with a wide variety of drug development expertise conducted a global Delphi exercise(1) including senior academics and clinicians, Royal College Presidents and Directors of Regulatory Agencies and Industry to launch a curriculum and Specialist Training Programme which aims to "ensure and maintain standards in the medical scientific discipline of Pharmaceutical Medicine". Within the last few months the first HMT Specialist trainees have successfully completed the rigorous and demanding programme leading to a Certificate in Completion of Specialist Training (CCST). This is a cause for celebration, and, will ensure expert scrutiny by Specialist Pharmaceutical Physicians concerned with all aspects of drug discovery, development, evaluation, registration, monitoring and medical aspects of the marketing of medicines for the benefit of patients and the health of the community. I look forward to the next 10 years of drug discovery and development with optimism now that Pharmaceutical Medicine has come of age. These new specialists should be empowered to counter the excesses of big pharma by harnassing a more ethical, scientifically robust and medically rigorous discipline in Pharmaceutical Medicine. Therefore, it is imperative that we support our specialist colleagues in their quest to develop innovative pharmaceuticals, meeting the needs of our increasingly aged population and the global challenges of infectious diseases, both old and new. 1.Millson D, Phelan M, Boardman H. Higher medical training in pharmaceutical medicine: Delphi Exercise on healthcare marketplace advanced modules. International Journal of Pharmaceutical Medicine 1999; 13 :285-8. 2.JCHMT curriculum for Higher Medical Training (HMT) in Pharmaceutical Medicine: www.jchmt.org.uk.Sept 2002 Competing interests: 10 years experience working as a Pharmaceutical Physician with Glaxo, ICI and Zeneca. Share and pension fund holder of pharmaceutical stock. |
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John Stone, none London N22
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This is an extremely opaque statement: "These new specialists should be empowered to counter the excesses of big pharma by harnassing a more ethical, scientifically robust and medically rigorous discipline in Pharmaceutical Medicine. Therefore, it is imperative that we support our specialist colleagues in their quest to develop innovative pharmaceuticals, meeting the needs of our increasingly aged population and the global challenges of infectious diseases, both old and new." Who will the new specialists work for, and how will their scientific objectivity be guaranteed? Competing interests: None declared |
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Roger N Chitty, Consultant Psychiatrist Cherrybank Resource Centre, 85, Wellington Road, Ellesmere Port, Cheshire, CH65 0BY.
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Dear Editor, Metaphors are interpretative devices of language that are used to aid one's understanding of the matter at hand. The metaphors of doctors as pigs and drug reps as weasels conjure up images of greedy doctors, unable to control their appetites, and sneaky drug reps, full of sophistry and sycophantic ways. Metaphorical language can be powerful in its persuasiveness, but such power depends on culturally shared asumptions about the meaning, or meanings, of the metaphor. United Kingdom doctors are urged to be armed with cynicism as a way of dealing with drug reps, but cynicism is a weak animal metaphor: conflicting images come to mind. To be a cynic is to be dog-like; but is this dog a guard-dog that will keep the drug rep at bay, or is it a poodle that is already licking the drug reps hand in a friendly and submissive way? Perhaps it is a mongrel, unable to resist snapping up juicy morsels thrown its way. Perhaps it is a dog that is barking-mad. Of course, the cynic as a philosopher condemns ease, wealth and the enjoyment of life, and in this sense the metaphor is apt as a basis for just saying no. However, cynics also sneer at the sincerity and goodness of human motives and actions, and sincerity and goodness are likely to be attributes of drug reps just as they are of most humans. For instance, drug reps bring important information about the benefits and harms of drugs new and old, to the attention of doctors. All in all, the word cynicism is cloaked in ambiguity. Would an owl be a better metaphor for the doctor in this situation? An owl is full of wisdom and discernment: able to make balanced judgements about drugs, drug reps and the pharmaceutical industry. Wisdom will be an aid in resisting seduction and will help to keep the relationship platonic. Unforunately, if pigs, weasels, dogs and owls were all to meet up there would probably be mayhem: fur, feathers and gore flying everywhere! Animal metaphors are a dangerous mix. Are there less metaphorical ways of description that aid understanding? It seems to me that the wise and discerning doctor is a sceptical doctor. Competing interests: None declared |
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ONASEGUN G OWONIKOKO, SHO,GENERAL SURGERY MAYO GENERAL HOSPITAL, CASTLEBAR,CO MAYO,IRELAND
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It is truly a very important issue.It strikes right down to the core of the integrity of the medical profession.Integrity is probably the greatest asset of the medical profession.When a doctor's integrity is compromised,he cannot be trusted by his patients and thus he cannot function effectively as a competent doctor. My experience and interaction with colleagues has shown that most doctors know their duty to the patient and the profession.Many doctors take advantage of the largesse that is thrown in their way by the ubiquitious drug reps-either through corporate means such as sponsorship of departmental seminars,training programmes and individually as highlighted in the article.However most doctors are discerning enough not to be 'bribed' by largesse handed out by drug reps on the back of drugs with spurious claims. Many a doctor may be 'pigs',but they are 'pigs' with conscience and insight. Segun. Competing interests: None declared |
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John Stone, none London N22
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Just to note that I sought elucidation about the role and status of the new breed of Pharmaceutical Physician Specialists in response to David Millsom's letter a couple of weeks ago, and no one seemed able to shed any light on the matter. Competing interests: None declared |
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Jackie Napier, Medical Director Schering Health Care Ltd, The Brow, Burgess Hill, West Sussex RH15 9NE
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In response to John Stone, and as one of the newly accredited specialists in Pharmacuetical Medicine to whom he refers, I hope the following comments will be of interest. Specialist training in pharmaceutical medicine involves a structured postgraduate training course over 2 years, culminating in an examination (the Diploma of Pharmaceutical Medicine), then a minimum of 4 years of on- the-job training, supplemented by additional courses as required. The Joint Committee for Higher Medical Training will regularly review the evidence of experience obtained over this period, exactly as with any other medical or surgical specialty. Many pharmaceutical physicians, such as myself, will enter the industry with higher medical qualifications such as MRCP or MRCGP, often with additional scientific qualifications e.g.a BSc or PhD. Most specialist pharmaceutical physicians will be employed directly by the Pharmaceutical Industry. However, this is certainly not incompatible with an ethical approach to patient care. When I first joined the industry, 15 years ago, my then boss (also a medic) told me always to remember that I was a physician first, and a pharmaceutical physician second. My role was to put the interests of the patient first and, if I did this, I would by default always be supporting the long term interests of the company and its shareholders. It is not difficult to see why this would be the case. The unsafe product, the poorly conducted clinical trial producing poor-quality data, the untruthful marketing campaign: if permitted to go ahead, any of these would potentially harm patients and hence will inevitably damage the product and the company concerned. The truth will always out. It is the legal responsibility of the pharmaceutical physician to monitor and approve the activities of our colleagues in clinical research, sales and marketing, to ensure that the required standards are met. It is what the industry employs us to do and it is specified in our objectives, against which we are measured each year. In due course, it will form part of our revalidation by the GMC. Whilst human error will always occur at times, and some drug-related tragedies will not be predicted or prevented despite everyone's best efforts, it's my experience that the vast majority of industry employees take a keen interest in patient welfare and will always do their best to promote it. Incidentally, this is not only true of the medics. I remain bemused by the anti-industry rhetoric which is now so widespread in the medical profession. Are we not all working towards the same aim? Has the pharmaceutical industry really contributed nothing of benefit to patients in the past 30 years? Perhaps I have been very fortunate with my employers, but I have certainly never been asked to compromise my principles as a doctor, nor have I met anyone who has been. More information about specialist training in pharmaceutical medicine can be obtained from the website of the Faculty of Pharmaceutical Medicine of the Royal College of Physicians (see Higher Medical Training), at http://www.fpm.org.uk/ Competing interests: I am an accredited specialist in Pharmaceutical Medicine, employed by a pharmaceutical company |
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John Stone, none London N22
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My thanks to Jackie Napier for her helpful, enlightening and quite certainly sincere response. I wish I shared her optimism or even the optimism I expressed above less than four weeks ago. Even if the truth becomes known is it not simply likely that it will be buried? Did the Health Committee report - which has huge implications for everybody - get significant media attention? Will anyone remember it now as Parliament reconvenes, anymore than a few weeks earlier the alarming report on VTEs, which flashed by without so much as newspaper editorial? Or what about the Burbacher study of thimerosal [1] and its results showing that more inorganic mercury accumulates in the brain of macaque monkeys than with a similar weight of environmental (methyl) mercury? This was reported by the BBC under the headline 'Blood "fast" to expel jab mercury'[2], and not reported at all by the BMJ. So, I disagree with Jackie. The truth is presently rather a marginal commodity, and can be kept under control most of the time by those with money and institutional influence. [1]http://ehp.niehs.nih.gov/members/2005/7712/7712.pdf [2]http://news.bbc.co.uk/1/hi/health/4472485.stm Competing interests: Parent of an autistic child |
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Michael D Innis, Director Medisets International Home 4575
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Editor, Jackie Napier says, “The unsafe product, the poorly conducted clinical trial producing poor-quality data, the untruthful marketing campaign: if permitted to go ahead, any of these would potentially harm patients and hence will inevitably damage the product and the company concerned. The truth will always out.” "The truth will always out." Yes indeed, but it the enormous damage done before it “outs” is what concerns the public, including some in the medical profession. The truth that vaccines can cause symptoms indistinguishable from the fabricated diagnosis “Shaken Baby Syndrome” still influences the judgments of the Courts in the UK, USA and Australia. Professor Clemetson’s work on the subject of vaccination [1,2], Dr Kalokerinos’ report on the lethal effects in an Aboriginal community [3] and my failed attempt to enlighten the profession on this issue [4] are examples of the truth being ignored or suppressed. “Outing” is not so simple when Medicine’s potential harm is questioned. Michael Innis PS I should mention that my paper, ‘Oncogenesis and Poliomyelitis Vaccine’ Nature 1968 219:972-3, was also rejected by the BMJ, and other medical journals. References: 1.Clemetson CAB Vaccinations, Inoculations and Ascorbic Acid. J Ortho Mol Med(1999) vol 14 No 3 137 – 142 2.Clemetson CAB. Child Abuse or Barlow’s Disease Medical Hypotheses 2002;59(1): 52-56 3. Kalokerinos A. Every Second Child. pp 27 –32 1981 Thomas Nelson (Australia ) Ltd 4. BMJ/2005/249748 Vaccine Induced Apparent Life Threatening Event Report of three cases misdiagnosed as Shaken Baby Syndrome or Non-accidental Injury Michael D Innis Decision: Immediate Rejection ; Decision Date: 27 Apr 2005 Competing interests: As previously declared |
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Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK
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The truth will always out is a wonderful philosophy. My first joint publication was about the effects of “Anovlar”, a Schering oral contraceptive product, in 1962.1 Many details of the adverse effects of progesterone-effect-dominant hormonal contraceptives, including increases in vascular and mental diseases, were known to the pharmaceutical industry in the 1960s.2-12 Why is it then that only in the past few years that large scale international epidemiological studies of current use of progestogens and oestrogens, given as HRT, have been stopped prematurely before more evidence of lethal adverse effects, like further increases in cancers, accumulated? In spite of these apparently "unexpected" and unwelcome findings ever younger females are being subjected to large doses of progestogens, for contraception or as the morning after pill (MAP), with the excuse that mortality is low among the youngest age groups. Many doctors are still not aware that progesterones cause depression and immune system dysfunction and are carcinogenic. Why not? 1 Mears E, Grant ECG. "Anovlar" as an oral contraceptive. BMJ 1962; 2: 75-79. 2 Grant ECG. The effects of oral contraceptives on the endometrium. 1964 Proc Soc for the Study or Fertility, Oxford Meeting; p275-6. 3 Grant ECG. Hormone balance of oral contraceptives. J Obstet Gynae Brit Com 1967; 74: 908-18. 4 Grant ECG. Relation of arterioles in the endometrium to headaches from oral contraceptives. Lancet 1965; 1: 1143-44. 5 Grant ECG, Mears E. Mental effects of oral contraceptives. Lancet 1967;1: 945-46. 6 Grant ECG. Relation between headaches from oral contraceptives and development of endometrial arterioles. BMJ 1968;3:402-5. 7 Grant ECG. Headache on the pill. BMJ 1968;3:619 8 Southgate J, Grant ECG, Pollard W, Pryse Davies J, Sandler M. Cyclical variations in endometrial monoamine oxidase: Correlations of histochemical and quantitative biochemical assays. Biochemical Pharmacology 1968;17:21- 26. 9 Grant ECG, Pryce Davies J. Effect of oral contraceptives on depressive mood changes and on endometrial monoamine oxidase and phosphatases. BMJ 1968;3:777-80. 10 Grant ECG. Venous effects of oral contraceptives. BMJ 1969;2:73-7. 11 Mears E, Vessey MP, Andolsek L, Oven A. Preliminary evaluation of four oral contraceptives containing only progestogens. BMJ 1969;2:730-34 (Grant ECG-pathology). 12 Anon (Grant ECG). Changing oral contraceptives. BMJ 1969;4:789-91 & in Today's Drugs. Competing interests: None declared |
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Peter KK Au-Yeung, Specialist Anaesthetist Hong Kong
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As an anaesthetist, drug firms are less interested in us as a group because our market is relatively small. This together with the loopholes in the drug and medicine laws in Hong Kong has led to a number of problems, including the non-availability of drugs with a proven track record in other jurisdictions. Business considerations can lead to drug firms not licencing particular indications, especially when they do not see a commercial advantage in it. The licencing of drugs for spinal (both subarachnoid and epidural) administration is particularly rigorous and to my knowledge, there has not been a licence for epidural fentanyl, though anaesthetists everywhere widely practise this off-label route of administration. When reluctance to licence leads to unavailability of a drug, that is another matter. The quarternary anticholnergic, glycopyrrolium bromide, is available in UK, Australia, etc. I used it in the UK before I went back to Hong Kong and my juniors need to learn about this drug to sit exams. However, as the drug manufacturer flatly refuses to licence it for the Hong Kong market, we have to make do with good old atropine to use with neostigmine in reversing muscle relaxation at the end of the operation. Slightly less ridiculous, and only because a workaround has been made using grey areas in the Law, is the lack of licencing for intravenous dantrolene. This is the gold standard treatment for the rare life- threatening condition of malignant hyperthermia, which occurs in susceptible individuals exposed to anaesthetics. To me, the refusal of the manufacturer to licence it in Hong Kong is a scandal. I am not advocating for any moment a cosy relationship between doctors and big Pharma, however, it seems to me inescapable that at least in the cases above, Hong Kong anaesthetists could be held ransom by the commercial interest of drug firms. Competing interests: None declared |
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Michael D Innis, Director Medisets International Home 4575
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Editor, My remark "The truth that vaccines can cause symptoms indistinguishable from the fabricated diagnosis “Shaken Baby Syndrome” still influences the judgments of the Courts in the UK, USA and Australia" SHOULD READ "The truth that vaccines can cause symptoms indistinguishable from the fabricated diagnosis “Shaken Baby Syndrome” still FAILS TO, repeat FAILS TO influence the judgments of the Courts in the UK, USA and Australia" I apologize for the error Michael Innis Competing interests: As previously declared |
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John Stone, none London N22
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Five weeks on their is not a breath of concern about the Health Committee findings in the Queen's Speech. And who can doubt that the next parliament will see a further drastic erosion of public accountability. It is just as if no one had ever said anything. Competing interests: None declared |
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