The Multinational Monitor


M U L T I N A T I O N A L   M A R K E T I N G

Appetite Stimulants for the Malnourished

by Charles Medawar

The consumer coalition Health Action International (HAI) is shortly to launch a campaign against the promotion of appetite stimulants, now widely marketed throughout the Third World. The main targets are the Swiss company, Sandoz, and the U.S.-based Merck Sharp & Dohme.

Underlying the HAI campaign is concern that appetite stimulants are being vigorously promoted in countries where malnutrition is rife. HAI argues this is no accident: "The temptation to promote drugs to achieve weight gain is great, if only because fear of malnutrition is an established part of life. The exploitation of this fear is what the promotion of these drugs is really about."

HAI contends that such promotions make nonsense of the drug industry's professed commitment - expressed in the industry's Code of Pharmaceutical Marketing Practice - to market drugs "which have full regard to the needs of public health." Appetite stimulants might benefit the odd patient in an exceptional case but when vigorously promoted as tonics are far more likely to do harm than good.

The other central issue is the question of "double standards." Both Sandoz and Merck Sharp & Dohme conduct their business abroad in a manner that would never be permitted at home.

Merck recommends its Periactin range of products for children, adolescents and adults, claiming it to be "the first clinically proven, documented and recommended appetite stimulant." However, in 1971, the U.S. Food and Drug Administration withdrew approval for the use of this drug (cyproheptadine) as an appetite stimulant for children - and approval for adult use was never given.

The promotional literature now used in Pakistan, for example, emphasizes that the benefits of Periactin are "well documented in journals of repute" - though it cites only two, largely irrelevant papers, published in 1970 and 1971. Though rarely adhered to in practice, the industry's marketing code does in theory require that "information should be based on an up-to--date evaluation of all the available scientific evidence, and should reflect this evidence clearly."

During 1984, Merck Sharp & Dohme carried out what they claim was a comprehensive review of their cyproheptadine products, including Periactin. They would therefore appear quite satisfied with the marketing of these products in this way.

The active ingredient in the Sandoz range of appetite stimulants is a drug called pizotifen (U.S.: pizotyline). Though Sandoz sells pizotifen in many Third World countries under the brand name Mosegor (for weight gain), in other countries, Sandoz sells the same drug under the name Sanomigran, as a treatment for migraine. The contrast in the promotion of these two products is striking.

In promoting pizotifen for weight gain, Sandoz trumpets patients' "highly effective" response, with "very good" stimulation of appetite in nearly 8 out of 10 cases, and claims significant weight gain for 9 patients out of 10.

When Sandoz promotes pizotifen for the treatment of migraine, however, all references to weight gain and appetite stimulation appear in small print, under the heading "side effects." One Sandoz publication on Sanomigran observes only that "a slight increase in body weight is observed in some patients. This is due to increased appetite."

There is certainly some evidence that use of either of these products can lead to weight gain in some patients - though it is far from impressive. The American Medical Association reports, for example, that the effect of cyproheptadine on children is "inconsistent, transient, and quickly reversible on withdrawal of the drug." But even if users do gain weight, there is no evidence of any substantial clinical benefit.

A review of the literature on appetite stimulants, carried out for HAI by Social Audit, overwhelmingly suggests these products do more harm than good. Damage may be done in several different ways.

First, promotion of appetite stimulants encourages myths and misunderstandings which are especially likely to cause problems in Third World countries where regulation of medicines is limited, and inappropriate self-medication the norm. The fallacy is that a reduced appetite or below average weight are medically significant conditions. What Dr. Benjamin Spock was saying in the 1960's still holds: "It's important to remember that children have a remarkable inborn mechanism that lets them know how much food and which types of food they need for normal growth and development. It is extremely rare to see serious malnutrition or vitamin deficiency or infectious disease resulting from a feeding problem."

Secondly - and this holds even if malnutrition is a problem - the important thing is to treat not the symptoms, but the underlying cause. Thus, acute loss of appetite in children is often an indication of an infection; it makes no sense to treat the loss of appetite, and it could be dangerous to ignore the underlying condition.

Finally, the promotion of appetite stimulants leads to waste of essential resources. A recommended course of MASSAGER costs about $10/ head. The World Health Organization estimates that $10/ head is precisely the investment needed to save "millions of lives a year," by providing essential health services in the poorest countries of the world.

It follows that Health Action International is determined to see these products withdrawn.

Charles Medawar is director of the British research organization Social Audit Ltd. Social Audit has prepared a leaflet on appetite stimulants, for distribution through Health Action International. The leaflet can be obtained from HAI, c/o International Organization of Consumers' Unions, 9 Emmastraat, 2595 eg The Hague, Netherlands.

Cigarettes for the South

In a recent letter, to the Guardian of England, Simon Chapman of the International Organization of Consumer Unions (IOCU) called attention to a little-noticed aspect of multinational marketing.

Cigarette makers, seeking to compensate for softening demand in major Northern markets, have turned their eyes Southward. From 1970 to 1980 the pool of smokers grew by a third in Asia and Latin America. International tobacco marketing practices are currently the subject of an IOCU campaign:

As the famine in North Africa developed during 1984, British tobacco companies were at work in the region reaping the bounty of aggressive promotional campaigns. Shipments of expensive tailor-made cigarettes from Britain from January to September 1984 were: Djibouti 270 million Ethiopia 153 million; Niger 59 million; Somalia 42 million; Sudan 541 million; and Bukina Fasso 78 million. These imports have to be paid for in the hard currency these countries so desperately lack thereby sapping their ability to pay for essentials like agricultural and infrastructural development.

Peter Temple, a British stockbroking analyst, advised the tobacco industry in 1983 that a major factor enhancing tobacco export possibilities from developed countries to the Third World was the "perception of cigarettes as an affordable luxury in the poorer areas of the world."

Tobacco advertising, as the cutting-edge of the industry's marketing program, gives mass currency to this totally cynical "perception." A British corporate director has stated that "where promotion is concerned, our managers in developing countries are aware that local practice should not be incompatible with promotional standards in the industrialized nations." Yet tobacco advertising in most parts of Africa involves some of the most lurid efforts anywhere in the world to associate smoking with dreamlike promises of prestige, power, freedom and luxury.

One need look no further than the absent health warnings on African ads to see just how hard British subsidiaries are climbing over themselves to ensure the parent companies' directives are followed.

Nowhere is the success of tobacco marketing more poignant than in those parts of the world where millions starve. People who do not smoke spend the money they would otherwise spend on tobacco on other items. Essentials like food, clothing, shelter and medicine are often far beyond the means of the millions of families on marginal survival incomes.

British doctor Nicholas Cohen has calculated that smoking five cigarettes a day in a poor household in Bangladesh might lead to a monthly dietary deficit of 8,000 calories. This is nearly a quarter of the monthly maintenance energy requirements (at 100 calories/kg/day) of a 12 kg child in Bangladesh. This means that each year the prospects for survival ,of some 18,000 children would be halved. Would British American Tobacco care to calculate its own contributions to the famine in North Africa?

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