By 2009, I was the Medical Superintendent of Kasturba Hospital. We had already built a firewall against the pharmaceutical industry in our classrooms. Conferences in Sevagram no longer ran on drug-company money, and our academic meetings had become quieter, leaner, and cleaner.<\/p>\n\n\n\n
But the hospital corridors were a different battlefield.<\/p>\n\n\n\n
Every morning, as the Outpatient Department opened its doors and the first patients began to queue up, a second stream walked in\u2014confident, brisk, and unmistakably out of place. Young men and women in crisp shirts and ties, hair neatly combed, shoes polished, carrying leather bags that looked heavier than a medical textbook.<\/p>\n\n\n\n
Medical Representatives.<\/p>\n\n\n\n
Their job was to sell, and they were very good at it. They hovered outside consulting rooms like seasoned hawks. They caught interns between wards and staircases. They slid into cabins in the tiny gaps between patients, timing their pitch with the precision of a commuter train. They carried pens, calendars, paperweights, prescription pads, pen drives, even reflex hammers\u2014small gifts, harmless in appearance, and therefore dangerous.<\/p>\n\n\n\n
The influence was not harmless. It rarely announces itself. It enters quietly and stays.<\/p>\n\n\n\n
***<\/strong><\/p>\n\n\n The first warning came from an unexpected place: our pharmacists.<\/p>\n\n\n\n They began to notice a pattern in prescriptions that did not fit the clinical picture. Bright, well-meaning residents were writing for expensive tonics, unnecessary multivitamins, and \u201cme-too\u201d brands that offered little advantage beyond glossy packaging. A patient with diabetes would walk out with a prescription for a high-end branded statin costing ten rupees a tablet when an equivalent generic sat on the shelf for one rupee.<\/p>\n\n\n\n Why this ten-fold leap?<\/p>\n\n\n\n Often, the answer was simple: an MR had been in the room.<\/p>\n\n\n\n The pharmaceutical industry understands psychology better than most doctors understand pharmacology. They know that a gift, however small, creates a subconscious debt. When a doctor accepts a pen, it is not a bribe. It is a hook. The doctor feels no shame, because the item is trivial, but the mind registers the exchange all the same: someone has done something for me.<\/em><\/p>\n\n\n\n And once you feel obliged to listen, you become vulnerable to persuasion.<\/p>\n\n\n\n There is enough evidence to show that doctors who interact with drug companies are more likely to prescribe expensive, non-rational medicines. Most of this is not corruption in the cinematic sense. It is seduction\u2014slow, polished, professional, and almost invisible.<\/p>\n\n\n\n That was when I realised I could not simply instruct my doctors to \u201cbe ethical.\u201d Ethics is not a slogan you paste on a wall. It is a discipline you must protect\u2014especially when young doctors are tired, overworked, and still learning the difference between science and marketing.<\/p>\n\n\n\n If temptation sits outside every consulting room, eventually someone will open the door.<\/p>\n\n\n\n ***<\/strong><\/p>\n\n\n So I issued an order that was bound to be unpopular.<\/p>\n\n\n\n Medical Representatives were no longer allowed inside the OPD and wards during hospital hours. No more cabin visits. No more detailing. No more hovering in corridors. No more gifts.<\/p>\n\n\n\n The reaction was immediate and noisy. Some colleagues were irritated. A few were genuinely anxious.<\/p>\n\n\n\n \u201cHow will we stay updated?\u201d they asked. \u201cMRs tell us about new drugs, dosages, side effects. They give samples for poor patients.\u201d<\/p>\n\n\n\n I had heard these arguments for years. They sounded reasonable until you examined them closely.<\/p>\n\n\n\n \u201cYou are doctors,\u201d I told them. \u201cIf you want to learn about a drug, read a textbook. Search the internet. Read a journal. Don\u2019t let a salesman teach you pharmacology.\u201d<\/p>\n\n\n\n And the \u201cfree samples\u201d? That story, too, had a sentimental glow. But the truth was harsher. Samples rarely reached the poorest patients in a systematic way. They helped a few, randomly. They often stayed with staff or travelled to favoured patients. They created dependence, not access.<\/p>\n\n\n\n A hospital that truly cares for the poor must build a system of affordability\u2014not rely on scattered charity from a company whose profits depend on expensive prescriptions.<\/p>\n\n\n\n ***<\/strong><\/p>\n\n\n Within days, the Medical Representatives\u2019 association demanded a meeting.<\/p>\n\n\n\n About fifty of them marched into my office. They filled the room, shoulder to shoulder, anger and anxiety mixing in their faces. They were not villains. They were young people trying to make a living in a system that rewarded aggressive selling. Some looked barely older than our interns.<\/p>\n\n\n\n Their leader spoke first. His voice trembled, partly with outrage, partly with fear.<\/p>\n\n\n\n \u201cSir, up to half of our business comes from your hospital. If you ban us, we will lose our jobs. How will we feed our families?\u201d<\/p>\n\n\n\n It was the classic livelihood argument\u2014emotionally powerful and not entirely dishonest.<\/p>\n\n\n\n I felt a pang of sympathy. I knew what unemployment looks like in small towns. I knew how quickly a household collapses when a salary stops.<\/p>\n\n\n\n But I also knew what a \u20b91,500 prescription does to a family that earns \u20b9250 a day.<\/p>\n\n\n\n So I told them, as gently as I could, what I believed was the truth.<\/p>\n\n\n\n \u201cI am not against you,\u201d I said. \u201cI am fighting the grip your industry has on my doctors. The way your companies make medicines seem better than they actually are makes doctors prescribe unnecessary drugs. That makes healthcare expensive.\u201d<\/p>\n\n\n\n Then I added the sentence that made the room go quiet.<\/p>\n\n\n\n \u201cYour presence here is a tax on my patients.\u201d<\/p>\n\n\n\n They listened, stiffly. Some looked away. A few stared at the floor. They had come expecting an argument about rules and permissions. They were not prepared to be told that their work, however innocent they felt it to be, was helping push poor patients into debt.<\/p>\n\n\n\n They left unhappy. But the ban stayed.<\/p>\n\n\n\n ***<\/strong><\/p>\n\n\n Removing the MRs from the corridors was only half the job. The harder task was changing the prescribing culture they had helped build.<\/p>\n\n\n\n We needed to de-program our doctors\u2014not by moral lectures, but by teaching them a new habit of thinking. We called it reverse marketing<\/strong>.<\/p>\n\n\n\n Marketing usually trains you to choose the most expensive item, the one with the best packaging, the most persuasive story. Reverse marketing taught our residents to do the opposite: choose the least expensive effective option.<\/p>\n\n\n\n We put up simple charts in clinics and wards. They compared brands, not by colour or company, but by molecule and cost.<\/p>\n\n\n\n One brand: \u20b9100 The point was not to shame anyone. It was to make the invisible visible. Once doctors saw the numbers in black and white, many felt embarrassed. Some felt angry\u2014at the industry, and at themselves. Most, to their credit, changed.<\/p>\n\n\n\n We trained them to look at the molecule, not the shine. We taught them that a \u201cgood doctor\u201d is not the one who can recite brand names like a jingle, but the one who understands the cost\u2013benefit ratio of every prescription.<\/p>\n\n\n\n ***<\/strong><\/p>\n\n\n Years later, in 2022, a biography of Dilip Shanghvi\u2014Sun Pharma\u2019s founder\u2014was published: The Reluctant Billionaire<\/em>. It read like a manual of how the industry works. How companies indulge doctors, inflate their self-esteem, cater to their unspoken desires, and shape habits without appearing to do so.<\/p>\n\n\n\n I remember thinking, with a mix of amusement and sadness: if our residents had read that book in 2009, they would have understood that they were not \u201cpartners\u201d in healthcare.<\/p>\n\n\n\n They were targets in a sales strategy.<\/p>\n\n\n\n ***<\/strong><\/p>\n\n\n It has been many years since we cleared the corridors. Today, the OPD in Sevagram feels quieter. The swarm of ties and leather bags is gone. Doctors sit in their cabins without being interrupted by a sales pitch delivered between two patients. When they write a prescription, they are not thinking of a pleasant young man outside the door or a pen on their desk.<\/p>\n\n\n\n They are thinking of the patient.<\/p>\n\n\n\n But the larger truth remains uncomfortable. MGIMS is an outlier. In thousands of hospitals across India, the siege continues. The invisible hand still guides the doctor\u2019s pen\u2014softly, politely, and relentlessly.<\/p>\n\n\n\n And every time it does, a poor family somewhere pays for it.<\/p>\n","protected":false},"excerpt":{"rendered":"The Invisible Hand<\/strong><\/h3>\n\n\n
The Ban<\/strong><\/h3>\n\n\n
The Confrontation<\/strong><\/h3>\n\n\n
Reverse Marketing<\/strong><\/h3>\n\n\n
Another brand: \u20b980
Our generic: \u20b915<\/p>\n\n\n\nThe Reluctant Billionaire<\/strong><\/h3>\n\n\n
After the Swarm<\/strong><\/h3>\n\n\n