Medical morals

Bribes and backhanders fuel deadly corruption but pharma is not the only player

Blood money. Colin Brown, CC BY

GlakoSmithKline (GSK) is currenlty feeling the heat from the allegations of foreign corruption that have erupted in China, Poland, Syria, Iraq, Jordan and Lebanon and the company is scrambling to restore its corporate reputation. Many other pharmaceutical companies have also been accused of corruption in recent times. Pfizer, Eli Lilly and Johnson & Johnson have all settled foreign bribery cases in the last three years.

The pharmaceutical industry is trying to deal with corruption and credit should be (cautiously) given where it is due. However, claims that rottenness is limited to a few bad apples is increasingly hard to sustain and it is important not to get hoodwinked by slick PR campaigns.

No immune system

You might think from the intense media coverage of pharma scandals that corruption in healthcare is primarily limited to these companies. Sadly, however, there is evidence aplenty that corruption pervades every aspect of healthcare. With a worth of US$6.5 trillion, the global healthcare industry is especially vulnerable. And although the problem is particularly acute in countries where corruption is endemic, no country is immune.

One of the most common forms of corruption involves informal payments to healthcare professionals. In Azerbaijan, for example, these “under-the-table” payments could account for as much as 84% of total health expenditure in the country. Even mortuary staff get in on the action. Kickbacks to doctors are also a common source of corruption in some countries. In India, for example, hospital administrators regularly give money to physicians to encourage patient referrals. Absenteeism is also very common. There are, of course, many legitimate reasons why people absent themselves from work. Sometimes work itself is the cause. However, corruption seeps in when physicians fail to turn up to work because they are busy boosting their salaries in the private sector.

Politicians, regulators, and even patients can also become mired in the moral quagmire. Fraud may add as much as 10% to the Medicare and Medicaid bill in the United States and some donor countries have suspended financial support to the Global Fund because so much money was being misused by bureaucrats. NGOs who might deliver health also aren’t immune.

Corruption kills

In a very broad sense corruption matters because it causes markets to be inefficient, erodes trust and undermines the very fabric of society. But corruption in healthcare is especially problematic because it exacerbates inequities, decimates the relationship between professionals and patients and violates the right to life. It achieves much of this grim harvest by reducing the total amount of healthcare resources that are available and by skewing the allocation of the resources that remain.

It also causes a lot of harm because it disproportionately affects women, children and the poor – which, incidentally, partly explains why the Millennium Development Goals will not be achieved by 2015.

Bluntly put, corruption matters because corruption kills and because it has a special penchant for killing the most vulnerable.

Slow off the mark

It has taken quite a while for politicians and policy makers to wake up to the scale and severity of the problem. Bioethicists like me have also been very slow off the mark. Fortunately, things have begun to get better. Transparency International published a landmark report on corruption and health in 2006 and in the last few years the United Nations, the European Commission and many other regional and international organisations have started to pay serious attention to the problem.

Many countries, including the UK and Italy, have also recently enacted anti-corruption legislation, and the US has even introduced legislation that specifically deals with corruption in the healthcare sector.

These improvements should not make us complacent for there is still much work to be done. Governments need to make sure that they enforce anti-corruption laws; doctors need to publicly pledge to clean up their profession; pharmaceutical companies need to redouble their efforts to systematically eradicate all their “bad apples”; universities need to forewarn and forearm healthcare students, and policy makers need to devise more sophisticated tools to measure corruption. Bioethicists also need to get their act together by analysing the problem of corruption and (more importantly) using their expertise to advocate for change.

When faced with overwhelming odds it is tempting to give up and claim that we are too few and they are too many. But this is simply not good enough, especially given that a bit of toil, sweat and (not a few) tears really can help to stop the rot.