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Asian Perspectives: Pharmaceutical Markets Trends and New Developments in Asia: Key Implication for Hong Kong/China
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Speech by Dr C H Leong
President of Hong Kong Academy of Medicine
at the MedPharma World Conference - Hong Kong 2002
on 8 August 2002
May I begin by thanking the organization for the invitation and the honor to open this congress and delivering the first keynote address.
I am here today representing the Hong Kong Academy of Medicine. For the sake of introduction especially to our overseas visitors, the Academy is a body established by statute to train, vet, and monitor standards of specialists in medical practices. We do this in conjunction with some 15 specialty Colleges under the umbrella of the Hong Kong Academy of Medicine. In short we recommend doctors to the Hong Kong registration body to be specialists, and ensure these specialists to be always in the forefront of medicine. We have our own purpose built premises and are linked on all CME/CPD programmes for both locally and worldwide.
The topic assigned is the "Asian Perspectives: Pharmaceutical Markets Trends and New Developments in Asia: Key Implication for Hong Kong/China". It is a topic I know very little about. First I am a surgeon, and I have therefore a very small pharmaceutical formulary. I always belief that surgeons treat patient with the knife and if they have to use extensive medications to improve their patients results, they are poor surgeons indeed. Secondly in the last few months the term "Market Trends" is a dirty word. In the United States we have heard of corporate scandals, even a few pharmaceutical giants are alleged to be involved. In Hong Kong, the "penny stock saga" has snowballed into more than a storm in a tea cup. Speculations are that some heads may roll in the high echelon of the financial, stock and exchange sectors to realize the Chief Executive's Accountable System.
I would therefore propose to discuss the topic of today under 4 areas:
- The Pharmaceutical Market consequent to the economy downturn and the health care reforms in Hong Kong
- The rebirth of Traditional Chinese Medicine (TCM)
- The rapid emergence of nutriceuticals or Health Food
- The role and responsibilities of the Pharmaceutical Industries in Hong Kong and Asia, as I see it.
The Pharmaceutical Market Consequent to Health Care Reform and Economic Downturn
In Hong Kong health care reforms begin with the establishment of the Hospital Authority (HA). The HA, for our foreign visitors, is a statutory body established to manage the public hospitals and specialist clinics using a yearly negotiate one line fixed government budget. Amongst many prerogatives, the HA is charge with running the public health care service of Hong Kong with the greatest cost efficiency.
With a drug budget of 2,640 million /annum (for drugs, medical supplies & instruments 2002/03), it is not difficult to realize that one of the ways to ensure an efficiency gain is to cut drug spending. This the HA has done through four initiatives.
- Obtain discount price through bulk purchase
- Utilize Generic Drugs when the patent expires and if the formulae of the generic products show similar composition and efficiency
- Reconsider the past habit and needs of issuing patients with 3 - 6 months drugs supply at every follow up;
Experience have shown that wastage do occur. Many are not taking the medicine as directed. Some return, asking for more drugs claiming they have lose the whole bagful. Occasionally too, bags of medicine are recovered from the disposal gabbage can right outside specialists and general clinics. To many patients the fact that so much medicine could be dished to them at one go only signifies that those drugs are of little value, if not little use. How sad!
- Judicious increase in the size of the public services formulary
Introduction of new pharmaceuticals are done with caution through proper debate in the very senior professionals level. Only those drugs consider to have real value and unique are added to the formulary. Expensive medications could only be prescribed with the approval of a senior professional.
All these are of course no cause for jubilation for our pharmaceutical industry. Yet to be fair to the HA, such actions are essential, for none would dispute that cost effectiveness must be the prime concern when tax payer money are being spent. On the other hand, HA must be forewarned that in no way must standards of services, efficacy of treatment be curtailed for money saving purposes.
More communications between the HA and the pharmaceutical industry must take place. The industry is part of the health care team, it should be considered by the hospitals management, the doctors, the nurses as partners, not just on a purchaser and a supplier relationship.
The economic downturn has brought on, of course, another negative impact. It has been said that Asians, in particular Chinese in Hong Kong would visit doctors for any minor ailments and request for medicines. Hitherto this has been the case. With the economic recession, much of these habits are now changed. Many today would ignore an ordinary cough and cold, or at most sought for some simple over the counter patent medicine.
Finally, whilst it is a global problem, it is perhaps more alarming in certain parts of the world, Hong Kong and China is no exception that illegally smuggling drugs are still rampant, in particular psychotrophic products. Facts show that whilst quantities of these drugs imported and utilized are properly monitored and stringently controlled through proper recording by manufactures, distributors and suppliers, pharmacists and doctors, a substantial amount are still available on an illegal basis across the counter in Hong Kong. No stone must be left unturned by the relevant government bureaux and departments to have this racket destroyed. For not only is it unfair to the pharmaceutical industry, the importers and suppliers, but is harmful to the population as this forms a major channel to perpetuate drug abuses.
The Rebirth of Traditional Chinese Medicine
The discover of penicillin and cortisone constitutes the so-called "modern therapeutic revolution". The 50s and 60s and the 70s were therefore the Golden days of Western or "scientific" medicine. Literarily, everyone, every pharmaceutical industry were jumping onto the band wagon of drug innovation - to discover new drugs, or new chemical entities to treat different diseases. Pharmaceutical scientists would be searching through maze of chemicals hoping to stumble on some hopefuls that would cure a disease. This was followed by a second wave, researchers having now know more about the biochemical workings of cells, chemical transmitters and how our cell communicate with another, are then moving into "designing drugs" to fulfil a defined function. Many no doubt have succeeded. To wit propanalol which block the beta-receptors in the heart to relieve sympromes of angina and cimetidine which blocks acid production in the stomach allowing ulcers to heal are classical successful examples.
Regrettably this "boom" could not be unabatedly maintained.
Firstly many so-called "new" drugs introduced were just more expensive treatment for diseases already taken care of by older and cheaper medicines. Secondly, whilst the need to introduce legislation to impose very stringent testing for new drugs after the "thalidomide" incident should be applauded, it has made R&D (Research & Development) for any new drug extremely expensive. Furthermore the "development time" of any new product is also markedly extended. To wit, in 1978 the development time for any new drug average 10 years whilst "development costs" escalate for some ¢G5 millions in the 60s to ¢G150 million in the 90s. Western medicine & medical cost will, as expect, soar at an exponential manner.
At around the same time, medical scientists have began to discover more and more up-to-date methods of investigations or tests that are supposed to help diagnosis and more accurately pin point diseases. So enthusiastic was the yearns for investigations that a new syndrome was at one time coined " Medical vampirism", where so much blood was taken for tests that patient become anaemic. Yes, the values of these investigations were never in doubt, yet each added investigation could only marginally increase the diagnostic accuracy. Furthermore many conditions could easily and accurately be diagnosed by the old fashion methods of "the art of Medical Practice".
Let me hasten to put the fact straight that I am not denigrating the values of all those modern update technologies. Nor am I fingering at the attitude of the service providers, many are driven to excessive or over investigations to satisfy their patients' demands or attempts to practice "protective and defensive medicine" facing "upsurge" and irrational medical litigations:
Needless to say the public feel the pinch of spiraling drugs cost, the morbidity of possible over investigation. All these only to diagnose and treat one disease, NOT the person in total. Many, rightfully, therefore lose faith in the western "scientific" "contemporary" medicine and wander with the arena of alternative medicine seeking holistic care - a total care for the person and not just a treatment of a disease.
Overnight alternative medicine soars into unscaled popularity.
In Hong Kong, Traditional Chinese Medicine as an alternative to Western Medicine took pole position and rightly so.
- TCM has existed in China for some 5000 years. Many successive kings and princes must be one time or another been beneficiaries of the practice. Yes some TCM may be proven to be quackery, yet many must be useful and valuable indeed.
- TCM is in no way an alternative medicine in China, in fact it is a main stream medical practice, though in Hong Kong it has been neglected for some 150 years as TCM was not recognized as a medical practice but rather a day to day Chinese tradition.
- The Basic Law of Hong Kong (our mini-constitute) stipulates that TCM will be developed in the same way as Western medicine.
- The Chief Executive of Hong Kong has promised in his policy addresses that TCM will be given high consideration and that it will be progressively introduced into the public medical service.
That TCM will take off and occupy a position in the spectrum of health care in Hong Kong is never in doubt. Yet today TCM still faces difficulties.
Firstly it is not enthusiastically supported by the western medical practitioners who take TCM as a threat, a competitor rather than a health care partner. Many have criticized that TCM lacks evidence based. This may well be, for the time being, evidence has never been explored.
Be that as it may, much needs to be done. To ensure that TCM could stand in the same level of professional respect as Western Medicine means that both TCM practice, TC Medicine must be stringently controlled as their Western Medicine counterpart. Yes TCM practitioners are bound by law to be properly registered, yet the control and regulation of TC Medicine, be it herbs or patent medicine, still leave much to be desired.
The fact remains however that as from now, the pharmaceutical industry, will be progressively facing the erosion of TCM. Many in the public are now looking towards TC Medicine as the first line of treatment instead of Western medicine be it to relieve discomfort or to increase vitality. Today some 10-15 percent of patients who needs primary health care seek the advise of TCM practitioners. The percentage is expected to increase.
It has always been said that "If you cannot fight them, join them". There is no reason why our well established pharmaceutical companies with their well established infrastructures could not take upon themselves to dwell on R&D for TCMedicine and come out with some winners!
The Rapid Emergence of Nutriceuticals
Perhaps frustrated by one's own chronic illness or bombarded daily with news of friends and relatives being sick, let alone failure of treatment, the public has loss faith in the discovery of a miracle cure nor do than actually believe that such drug exist. Instead, most are now searching for potions that could sustain if not improve health. In a society which is fast aging, sustaining health is even more important. People, as they grow old, will be concerned with failing health in general, poor memories, joint deformations and physical disabilities in particular.
Spurred also by the worry of ingestion of synthetic materials and chemicals, most are looking for natural products. It therefore is of no surprise that manufacturers are taking every opportunities, jump onto the bandwagon to produce and market natural products as health foods - ginkgo nuts, sunflower seeds, fungal powders and aloe alvera etc dons display counters of super-markets, pharmacies and dispensaries - all claim in one way or another of multipotency in improving health, increasing vitalities and curbing if not reversing aging process etc.
Along the same line is the crave for "beauty" - Skin products and slimming formulae sell like hot cakes, though in many the effectiveness is very much in doubt. Imaging that as advertised, one can slim down after drinking a solution, sleep for a few hours and wake up and lose your waist line without having to go through the ordeal of cutting down on food intake or vigorous exercise. It is just too good to be true.
Let us make no mistake, improving one's health must be any persons wish and every nations hope. Similarly, to look "beautiful", to improve ones physical appearance must be the perogative of any individual, irrespective of gender or age. Yet what we witness today, what is in the market, leaves a lot to be desired.
Firstly, these health foods or nutriceuticals are not required to prove their efficacy and effectiveness. In short there is no consumer protection. So long as the advertisements stay clear of claiming to be effective in treating named diseases, they do not contravene the "Undesirable Medical Advertisement Ordinance" and stay therefore on the right side of the law.
Secondly, as a health food and a natural product, there is no requirement for registration of the ingredients nor random sampling be analyzed to determine whether any of the contents are harmful to health or whether there are western medicine or heavy metals in the ingredients. The public's health is thus not protected. In fact reports elsewhere indicate that some of the so-called slimming formulae from natural products have produced health complications and loss of life.
In short there is currently NO regulations on health foods or nutricenticals. As long as the product is a natural product and that possess no western medicine nor heavy metals, that product is out of reach of the long arm of the law. Something needs to be done and done with urgency if our public's health and consumer's right are to be properly protected.
It may sound paradoxic, yet fact states for itself. In these days of economic depression, in these days of decrease in business in the consumer market, the sale of health foods, skin beauty products stand tall above the rest, increasing sales against all odds.
What does all these means? To me it symbolizes that the society of ours is becoming more health conscious, that individuals are looking for a better quality of life through being more self confident from a more acceptable physical shape and built. The health care team, the policy makers and the government should capture on this. It is high time that the message "health is everybody's own responsibility" should be spelt out loud and clear.
The Role and Responsibilities of the Pharmaceutical Industries
Finally I would like to express my feeling on the role and responsibilities of the pharmaceutical industry. If what I am going to say seem harsh to the relevant bodies I do apologize. I am looking at 3 areas.
- Pharmaceutical Industry supporting basic scientific researches
Hong Kong has always excel in clinical expertise and clinical research. Our Health care professionals are universally sought after for their clinical excellence. Yet in the area of basic scientific research we have not shine in the same way. I do not believe that we do not have the brains nor the manpower. I believe that the stumbling block is the lack of adequate financial support for basic research, and basic research must be the kingpin of any medical development. I believe the pharmaceutical industries can do much in this direction i.e. support basic research. After all helping us, helping the budding medical scientists is helping you too. There are all the possibilities that a vaccine for AIDS, a panacea for all cancers could be just round the corner in our local community.
- Pharmaceutical Industry taking a lenient stand on patent rights on global life saving drugs
I am here referring specifically to medicines used to sustain patients with AIDS. In 1996 at the height of success of the "cocktail treatment" for sustaining victims with AIDS the theme of the then International AIDS conference in Vancouver was "one world, one hope". Whilst the cocktail therapy is a shadow of hope for those HIV positive, yet the treatment was so unaffordable to the poor and the poor countries and nations mainly in the Sub Sahara African countries where AIDS originate and where the numbers inflicted are incalculable. Yes, there is one world, one disease, yet many have no hope because they cannot afford the treatment.
In the subsequent International AIDS conference, a senior judge from South Africa where the meeting was held came out with the same message. He himself is a HIV carrier, his life is sustained, he could carry on with the work because he could afford the treatment whilst others in his country are dying every minute not because there is no treatment but because it is unaffordable as the relevant pharmaceutical manufacturers are not willing to relax its patent rights.
The same is occuring to China and many Asian countries where the HIV virus are expanding. Regrettable, AIDS are associated with poverty and backwardness. Paradoxically these are the countries that cannot afford to provide their victimized people with the drugs, yet they need the treatment desperately.
Things have improved much since, to our delights. I will be the last one to call for abandoning patent rights knowing the vast expense any drug firm has to invest to produce any meaningful drug, yet when it comes to a life saving issue, a health issue that affects the whole world, an issue that borders on a global epidemic, I look forward to our pharmaceutical industry to stretch out its "Samaritan hand".
- Pharmaceutical Industry to be more understanding to the doctors' needs
The Pharmaceutical industry is a business and like all business it thrive on profit. This is just natural.
All pharmaceutical manufacturers do produce many products, some have a better market than others, some make a better profit than others. It stands to financial reason that drug firms and local agents would be prone to import or stock more of the more popular products and ignore the others.
Yet when there is such a drug in the formulary there will be users, especially for chronic illness where life depends on that product.
I call upon on local pharmaceutical firms to balance the need for effective profit gain and services, a service which is not for the medical providers but for the end users, the patients, whose life could be dependent on it.
Mr Chairman, Ladies, and Gentlemen, in the last 30 minutes or so I have managed to skim through my thoughts or the topic you have so assigned to me basing on the issue that we all: the pharmaceutical industries, the doctors, the TCM practitioners, the nurses, the allied health care professions are partners in the health care team. We should have one motto, one hope - a healthier people and a healthier society for tomorrow.
I thank you.
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