I went to a drug rep dinner tonight discussing a new PrEP medication tonight at one of the most expensive restaurants in Missoula this evening. It is honestly an incredible field of research and has the potential to eradicate HIV from the planet if allocated appropriately. However, I can’t help but leave the evening with a feeling that I sold my soul to big pharma.

For the last 6+ years I have avoided drug reps completely, refusing to take their merchandise, samples, pamphlets, meals, whatever they shove in our faces on the reg. Early on in med school, after enjoying several free meals provided by pharma companies, I learned the truth and started packing a lunch. The reality is always: it is the patient who pays for those meals. Big dog CEO makes bank off these meds and displaces any of these extravagant dinners onto the patients. If the patient isn’t paying for it, their insurance company foots the bill for it (ie the patient still pays for it in their premiums/copays/deductibles/taxes). So to all my patients on PrEP, thanks for the dinner tonight and I’m truly sorry.

I realized tonight though that me declining these advertisements/bribes/incentives is a privileged thing. My staff at my clinic routinely take the lunches while the docs refuse to engage with these salespeople. We, as the docs, never pay for our staff to have lunches yet we willingly allow reps to come in and feed out staff. Even though I am uncomfortable with eating the food myself, I allow them to come in because it makes the employees in the clinic happy and well fed. The solution to this is to decline reps and have the docs/clinic fund lunches several days a week. Easy problem to solve.

The problem with pharmaceuticals in 2024 and the extremely unregulated marketing with them in the United States is weirdly that the drugs are too good. A doctors job has always been a difficult one due to difficult to treat conditions. Mortality rate for all of us is, in 2024, still 100%, the common cold has practically no really useful treatments, cancers are still often debilitating and fatal, etc. But with each passing year, pharma companies develop incredible disease altering meds. They can often, with minimal side effects, practically cure ulcerative colitis, rheumatoid arthritis, lupus, psoriasis, HIV, hepatitis C, type 2 diabetes, eczema, and a whole host of other previously debilitating diseases. Thanks to GLP1 agonists (injectable diabetes and weight loss medications), for example, the national rate obesity will likely start declining for the first time. Medications historically were relatively crappy. They had atrocious side effects and were not that effective. We as docs looked like idiots because most things were largely untreatable. That is quickly changing and with these incredible meds, pharma companies are making bank and it’s only going to get better for them. Patients really want these meds and often all but standing in line to receive multithousand dollar a month medications.

With these incredible new meds, these companies can charge a fortune. They advertise predominately to people who they believe can afford the medications and direct their efforts to high yield audiences where they can make the most money. The problem, specifically in PrEP is that the populations that are most likely to benefit from these meds are the least likely to receive them. The black and latino populations in the US are being disproportionately affected by HIV. But the healthcare system, including pharma companies are massively failing them. We have all these contrived, extremely exhausting workarounds for getting insurance coverage, prescription coupons, federal grant funding to afford these meds but all of this takes privilege, support, allies, community and legislator support.

I’m not sure of a solution to all of this. Capitalism and greed have prompted pharma companies to research and develop these incredible meds knowing there is an astronomical amount of money to be made. Capitalism has served a role here. I wonder about abandoning the capitalistic system and just providing taxpayer funded research for meds. It for sure would be cheaper, would probably provide more equitable research and research meds that are to treat rare conditions more often, but with our social regression recently is certainly one of my socialist pipe dreams.

Whatever the solution, I know we can abandon drug marketing. We can seek our own knowledge from our professional societies, colleagues, government agencies, and other academic resources. We can outlaw the expensive direct to consumer advertisements and refuse the tasteless bribes to healthcare professionals. I will go back to avoiding drug reps. I will hang my head in shame over my acceptance of a bribe this evening and hopefully do some good tomorrow to make up for it. If someone ever grills me in front of a congressional committee as they did to Dr. Fauci, asking him how much money he accepted from pharma (shocker, he accepted none), I will hang my head and disclose this dinner.