[PAA-Discuss] Fwd: [wildestcolts] Without consent: how drugs companies exploit Indian 'guinea pigs'

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From: Jim Moore <mofunnow at swbell.net>
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Sent: Mon, Nov 14, 2011 1:39 pm
Subject: [wildestcolts] Without consent: how drugs companies exploit 
Indian 'guinea pigs'






http://www.independent.co.uk/news/world/asia/without-consent-how-drugs-companies-exploit-indian-guinea-pigs-6261919.html 


Without consent: how drugs companies exploit Indian 'guinea pigs'



Illiterate patients say they never agreed to take part in trials run by 
industry worth £189m
Andrew Buncombe, Nina Lakhani


Monday 14 November 2011



Western pharmaceutical companies have seized on India over the
past five years as a testing ground for drugs – making the most of
a huge population and loose regulations which help dramatically cut
research costs for lucrative products to be sold in the West. The
relationship is so exploitative that some believe it represents a
new colonialism.

Since restrictions on drug trials were relaxed in 2005, the industry in 
India has swollen to the point where today more than 150,000 people are 
involved in at least 1,600 clinical trials, conducted on behalf of 
British, American and European firms including AstraZeneca, Pfizer, and 
Merck. There may be more.
While there is no official figure, some estimates suggest the industry 
may be worth as much as £189m. Regulators have struggled to keep pace 
with the explosion. Between 2007 and 2010, at least 1,730 people died 
in India while, or after, participating in such trials. Many of those 
people, often only eligible for the studies because they were ill, 
might have died anyway. Yet when there are complications, even those 
resulting in deaths, there is often a failure properly to investigate.
Campaigners say the industry is wide open to other abuses. While there 
is no doubt many crucial trials are carried out according to the 
appropriate guidelines, activists say a lack of oversight has led to 
numerous situations where poor, sometimes illiterate individuals, 
recruited from city slums or else tribal communities, are used in the 
trials without giving proper informed consent – that is, without fully 
understanding what they are signing up for. Alongside this, a new 
industry providing participants for these studies has been spawned and 
is making considerable profits.
Among some of the incidents confirmed by aninvestigation carried out by 
The Independent in the states of Madhya Pradesh, Andhra Pradesh, as 
well as in Delhi and London, were:
* The recruitment of hundreds of tribal girls without parental consent 
for an immunisation study sponsored by the Bill and Melinda Gates 
Foundation on the nod of the warden of their government hostel. Several 
girls subsequently died. The study was halted by the federal 
authorities.
* The use by drug companies of survivors of the world's worst poisonous 
gas disaster in Bhopal as "guinea pigs" in at least 11 trials without 
proper informed consent.
* The completion by doctors at a government hospital in Indore, in 
central India, of dozens of private trials that a police investigation 
found "violated the ethical guidelines". The doctors who conducted the 
trials decided that not one of 81 cases in which a participant suffered 
an adverse effect was linked to the treatment. New trials were stopped 
while the state government investigated. A whistle-blower was fired.
India is just one of many developing countries used by leading Western 
pharmaceutical companies, which spent £40bn in 2010 on research and 
development. Globally, it is estimated around 120,000 trials are taking 
place in 178 countries.
Companies can reduce their research costs by an estimated 60 per cent 
by outsourcing the work. China, Indonesia and Thailand are among the 
countries which have also seen the incidence of trials soar in recent 
years. A quarter of all clinical data submitted to European drug 
regulators to secure market approval for a new drug has been obtained 
 from trials in low- and middle-income countries. Confidential data from 
drug companies suggests this has recently increased to closer to 50 per 
cent.
Campaigners say India is a particularly attractive location for 
researchers not simply because of the lax regulations but because of 
the size and genetic diversity of the 1.2 billion population and 
becuase of the variety of conditions to treat. Added to this, almost 
all doctors speak some English. The infrastructure for such trials, 
often in the form of government hospitals, is widely available.
The loosening of regulations did away with a measure that had been put 
in place for the protection of trial subjects. Previously, for a phase 
three trial of a drug (when it is given to a larger sample of 
individuals) to be carried out in India, that phase of the trial had 
already to be have been completed elsewhere. Now they can run 
concurrently.
A comprehensive picture of the situation regarding drug trials in India 
following the 2005 amendment to the Drugs and Cosmetics Act is not 
available because of a lack of transparency and because various 
agencies are involved in the monitoring of the situation. Instead, much 
of the information has been gathered by unpaid activists using the 
country's Right to Information Act.
Much of the data has been collated by Dr Chandra Gulhati, a retired 
physician who edits the Indian Monthly Index of Medical Specialties, 
and who pulls together information from across the country on trials 
going back more than a decade. In his office in Delhi, Dr Gulhati 
described how lack of oversight and vested interests had created an 
environment in which many leading institutions had been involved in 
trials that breached national and international guidelines.
Dr Gulhati said figures released by the authorities suggested around 
1,730 people had died following their participation in trials between 
January 2007 and December 2010. Whether all of these died directly as a 
result of the trial is unclear; many of those who participated may 
already have been severely ill and would have died anyway. He claimed 
there was an absence of clarity because it was left primarily to the 
doctors overseeing the trial, the ethics committee and the drug 
companies themselves to determine whether there was a link.
Earlier this year India's Health Minister, Ghulam Nabi Azad, told 
parliament that a total of 10 foreign drug companies had made payments 
to the relatives of 22 individuals who had died during or following 
trials in 2010. The payments came to an average of just 238,000 rupees, 
or £3,000, for each individual. "Indians are being used by companies to 
make money selling expensive medicines in the West," claimed Dr 
Gulhati. "[They are] using illiterate and poor Indians who will never 
be able to afford these kinds of medicines."
The companies who made the compensation payments were: Pfizer, PPD, 
Bristol-Myers Squibb, Amgen, Bayer, Eli Lilly, Quintiles, Merck KGaA, 
Sanofi-Aventis and Wyeth, which is now part of Pfizer. When contacted, 
most of the companies declined to provide details of the compensation, 
other than to say the figure had been agreed in conjunction with a 
supposedly independent ethics committee and the Drug Controller General 
of India.
A spokeswoman for Eli Lilly also explained that payments totalling 
£6,340 had been made to the relatives of three individuals who died 
while participating in a trial of Pemetrexed, an anti-cancer drug. All 
three were in the advanced stages of cancer. "The causes of death were 
 from known drug-related side effects which were already listed in the 
package insert," said Dr Anurita Majumdar, a medical adviser to the 
company. "These events do not lead to death in all patients but can get 
compounded in certain patients who have poor general condition and 
nutritional status." Ms Majumdar added: "We were not advised by 
regulators to stop the trials."
Drug companies insist they always adhere to regulations. In a 
statement, the Association of the British Pharmaceutical Industry said: 
"In order for a pharmaceutical company to gain a licence in the UK for 
a newly developed medicine, the clinical trials, wherever they took 
place, are subject to a high level of scrutiny by the UK regulatory 
authorities. It would be of no benefit to companies to conduct clinical 
trials that were not of the required standard, as any medicine would 
not gain a licence and not be made available to patients."
While the Indian media has often focused on deaths that have resulted 
 from trials, campaigners say perhaps a bigger issue is the routine 
exploitation of those who participate in them – individuals who are 
often poor, ill-educated and unable to read and write.
Many participants said in interviews that they agreed to take part 
simply because of the recommendation of their doctor, who was very 
often the person conducting the trials. Since many of those selected to 
take part are from some of the very poorest communities, individuals 
have little possibility of redress.
Dr Anand Rai, a former doctor-turned-whistle-blower in the city of 
Indore, said many of the people recruited for trials at the city's 
Maharaja Yeshwantrao hospital were from the tribal community.
"There are ethical violations at every level," said Ms N Sarojini, 
director of the Sama resource group for women, which recently held a 
forum on clinical trials. "There is a lack of accountability, a lack of 
monitoring and regulation."
International guidelines have been formulated to protect the rights of 
trial subjects. They stipulate that the interests of the individual 
should take precedence over the good of science. Every drug company has 
policies which conform to these standards. In reality, say activists, 
these are not adhered to.
The swelling controversy in India has reached the point where the 
country's parliament was recently told by Brinda Karat, an MP who has 
called for investigations into abuses: "There is a gross violation of 
guidelines and laws concerning clinical trials in our country."
Campaigners say the lack of regulation is underscored by the situation 
regarding ethics committees, from which every institution carrying out 
a trial must receive approval. Such is the laxity in the guidelines 
that almost anyone can be part of such a body.
Dr Amar Jesani, editor of the Indian Journal of Medical Ethics, said he 
was asked to join such a committee at a reputable teaching hospital 
where there were more than 50 trials registered as ongoing. "There was 
no organised information about the trials or subjects. When I started 
going through the protocols so that I could properly assess the study 
question, the other members said it was the first time they had ever 
read the protocols," he said.
Indian government officials claim the system includes checks and 
balances which are being continually improved. In an interview, Dr 
Vishwa Katoch, director general of the Indian Council of Medical 
Research, said: "In the last 15 years there has been a remarkable 
improvement in the functioning of the ethics committees."
Case study: Sarita Kudumula, 13 - Parents only knew Sarita had been in 
a study after she died
No one told the parents of 13-year-old Sarita Kudumula that the 
teenager was involved in a medical study. They first they knew of it 
was after she collapsed and died, some days after receiving the 
injection. Discovered on the floor of a relative's home, the young girl 
was rushed first to the local clinic and then to the nearest hospital. 
By the time they got her there, she was already dead.
The teenager had been part of a study carried out in a remote part of 
the southern Indian state of Andhra Pradesh (AP) to test the 
feasibility of vaccinating large numbers of young women against the 
Human Papiloma Virus (HPV), which is sexually transmitted and is one of 
the causes of cervical cancer. The trial, administered in conjunction 
with the state government, was led by a US-based NGO, Path, which 
received millions of dollars from the Bill and Melinda Gates 
Foundation. Samples of an anti-cancer vaccine, Gardasil, produced by US 
company Merck, were provided free of charge. Officials wished to know 
whether the vaccine could be introduced as part of a national 
immunisation programme. Up to 74,000 women in India reportedly die from 
the disease every year.
It seems unlikely that Sarita died as a result of her participation in 
the study. No one knows exactly what led to her death or those of six 
others involved in the study in AP and the western state of Gujarat, 
where another drug, Cervarix, produced by GlaxoSmithKline, was used 
instead of Gardasil. Both Path and Merck insist that Gardasil is safe. 
A post-mortem carried out after the girl's death suggested she had 
committed suicide – a conclusion her parents refuse to accept. A 
subsequent investigation by the federal government – which suspended 
the trial after the deaths sparked controversy – concluded it was 
unlikely the girls had died as a result of having been given the 
vaccine.
In a sense, though, the cause of Sarita's death is besides the point. 
What is beyond dispute is that Sarita's father and mother, Nageshwara 
and Venkatama, and the parents of hundreds of other tribal girls, were 
not informed their daughters were taking part in a trial – something 
that is in breach of guidelines laid down by the Medical Research 
Council of India, which demands that those participating in trials give 
"informed consent". Sarita's family are adivasis, tribal communities 
who are among the most vulnerable in India, and Sarita attended a 
government school and hostel, located a few miles from her home. Only 
tribal girls attend.
"Nobody came to ask us for permission," said Sarita's father, a farmer, 
sitting outside his thatched hut in the village of Anjipakka, as he 
remembered his daughter, who died in January 2010. "She enjoyed the 
hostel. She was a bright student and took part in all the social 
activities. She was intelligent. She wanted to become a doctor."
When The Independent visited the pink-painted Government Girls' Ashram 
and High School in the nearby town of Bhadrachalam, the hostel warden 
confirmed that health officials had come to the hostel and outlined 
their plan to vaccinate 300 girls. He said that because it was a 
government project, he had been told he could authorise the trials 
without parental permission. "We did not show any forms or ask for the 
signatures of the girls or the parents," he said. The warden claimed 
the vaccination programme went off without a hitch.
While the government inquiry did not link the vaccine to the death of 
the girls or suggest there had been a "major violation of ethical 
norms", members of the enquiry panel were concerned that tribal girls 
had participated in the study without consent. "The most significant 
deficiency in the implementation of the trial was the obtaining of 
consent," said one finding.
Officials at Path's India office say the study was carried out after 
the vaccine was already licensed and was not strictly a clinical trial. 
"Among over 23,000 girls vaccinated [in AP and Gujarat] through the 
project, seven girls passed away, but the deaths occurred weeks or 
months following vaccination," said Tarun Vij, Path's country head. 
Regarding consent, he said: "The state government authorised the 
wardens to provide this consent for girls who were living at 
residential schools."
Spokesmen for the Gates foundation, Merck and GlaxoSmithKline all 
emphasised that the drugs involved in the studies are safe. A 
GlaxoSmithKline spokesman added that the trials were carried out 
according to the same standards wherever they were conducted in the 
world. On the issue of consent, Gates foundation spokesman Chris 
William said: "The implementing partner on the ground (the state of AP) 
made the decision to empower headmasters to provide consent for this 
licensed vaccine in some special circumstances. We haven't seen 
anything that would suggest that the decision should be second-guessed."
Case study: The Naik family - 'To us a doctor is like a god. We believe 
them'
Over four years, a close-knit team of senior physicians at the MY 
hospital in Indore secured and conducted dozens of prestigious trials 
with drug companies from around the world. They were paid about 50m 
rupees (£625,000). The doctors insist their work was carried out 
according to guidelines and an ethics committee oversaw what they did.
But to others, there were causes for concern. Funding for the study was 
given to the doctors involved and not the hospital. It was not clear 
that participants fully understood what they were volunteering for. And 
the only doctors to investigate 81 cases where patients had problems 
after trials were the same doctors who conducted them.
In the summer of 2010, the state government prevented the hospital from 
conducting new trials while it held an inquiry. A separate, 
non-criminal police investigation found doctors had "violated the 
ethical guidelines on a number of occasions" and that the "fundamental 
concept of informed consent was also overlooked".
Dr Anand Rai, a physician formerly employed at the hospital who turned 
whistleblower and was subsequently fired, says that in 81 serious 
adverse events (SAEs) following 60 trials involving up to 3,000 
patients – including one case where a trial subject died – not one was 
listed as having been the result of a trial and not one person received 
compensation.
"To us, a doctor is like a god. We believe everything he says," said 
Ajay Naik, 28, whose baby son, Yatharth, developed white spots on his 
skin after a trial. "My wife was told a new multi-vaccine had come that 
costs 8-10,000 rupees and that it was available free of charge." They 
had no idea they were involved in a trial. "There was a two-page form 
in English. No one read out the details," he said.
The five doctors named in the complaint to the police adamantly deny 
wrongdoing and claim they are victims of false allegations levelled by 
the media and campaigners. Dr Pushpa Verma, one of the physicians 
involved, said the allegations had been made by "uneducated people" and 
that the police were unqualified to investigate the matter. She added: 
"There were no ethical violations."




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