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[e-drug] NYT: Driven to Suicide by an ?Inhuman and Unnatural? Pressure to Sell (India)

E-DRUG: NYT: Driven to Suicide by an ‘Inhuman and Unnatural’ Pressure to Sell 
(India)
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NYT - International Business

Driven to Suicide by an ‘Inhuman and Unnatural’ Pressure to Sell
By GEETA ANAND and FREDERIK JOELVINGAUG. 11, 2016

Warning:  THIS IS A LONG ARTICLE: Morderator

http://www.nytimes.com/2016/08/11/business/international/abbott-india-suicide-inhuman-drug-sales-tactics.html?emc=edit_tnt_20160813&nlid=54807877&tntemail0=y&_r=0

(With photos on the original webpage)

INDORE, India — Leaving his wife and two young children home on a recent 
Sunday, a 27-year-old salesman for Abbott Laboratories’ operations in India — 
in fact, one of the American health care company’s top performers there — rode 
his motorcycle to a remote railroad track and jumped in front of a train.

In his pocket, a note in blue ink, handwritten in a mix of Hindi and English, 
said, “I’m going to commit suicide because I can’t meet my company’s sales 
targets and my company is pressuring me.”

Ashish Awasthi’s death last month resonated across India and through the halls 
of the health care giant. More than 250 fellow Abbott drug representatives in 
India walked off the job for a day, protesting what some called the company’s 
overly aggressive sales policies. A national union of drug sales workers called 
for new government rules to rein in sales practices industrywide, saying they 
compromised patient health.

A six-month investigation by The New York Times found that in the push to win 
customers in India’s chaotic and highly competitive drug market, some Abbott 
managers instructed employees to pursue sales at virtually any cost — in 
violation of Indian law, professional medical standards and the company’s own 
ethics guidelines.

Sales jobs with global powerhouses like Abbott are highly prized positions in 
India. But they can also be extremely demanding, putting employees under 
inordinate pressure to cut corners, according to interviews with more than a 
dozen current and former sales representatives and managers and a review of 
internal Abbott communications provided by two of them. In one of the most 
common practices, The Times found, Abbott managers told sales staff to hold 
what the company called health camps, where representatives would perform tests 
on patients for various ailments in an effort to drum up business for doctors, 
who would then prescribe Abbott drugs. The camps were typically held at 
doctor’s offices or as community events.

Sales personnel who perform screening tests could be accused of practicing 
medicine without a license, a criminal offense, said Dr. Jayshree Mehta, 
president of the Medical Council of India, the country’s medical regulatory 
agency. Indian medical ethics regulations also prohibit quid pro quo, Dr. Mehta 
said.

Abbott India’s public affairs director, Anand Kadkol, said the company’s 
marketing policies “are aligned with applicable laws” in India. He called the 
health camps “disease awareness education programs” and said that Abbott’s 
policies did not allow the camps to be conducted “in exchange for an explicit 
or implicit understanding” to prescribe Abbott products. The company declined 
to comment on individual employees. Mr. Kadkol said Abbott was “aware of a 
number of the allegations raised” and had addressed them.

But Vivek Gupta, a former manager of a sales team in northern India, said he 
was fired last year under pressure to make his sales representatives do more 
screenings of patients to promote a new Abbott multivitamin for nerve damage. 
He tried to resist, he said, out of respect for the national rules and the 
company’s own policies, which prohibit the use of health camps to influence 
which medicines are prescribed.

Dhirendra Yadav, 26, a former sales agent in central India in the neurology 
division, said he resigned in December 2013 under what he called “immense 
pressure to conduct business in unethical ways.” He said his former manager — 
who later became the manager of Mr. Awasthi, the man who committed suicide — 
insisted that he use his own money to buy medicines costing nearly 15,000 
rupees, or about $220, to help his group meet a sales target. That would be 
more than half of a typical representative’s monthly pay.

Rajeev Khanna, who managed six sales representatives for neurology medicines in 
northern India, said he was fired after complaining to Abbott’s office of 
ethics and compliance that his team was submitting fake invoices to increase 
sales. He described a practice of giving discounts intended for government 
institutions to private wholesalers as a kickback.

Corruption, already pervasive industrywide in India, has intensified with 
growing competition, according to the Federation of Medical and Sales 
Representatives’ Associations of India, the largest union of drug sales 
personnel, representing tens of thousands nationwide, which called for the new 
regulation.  Unethical marketing practices are routine in the Indian 
pharmaceutical market, said Sanjeev Khandelwal, a union secretary who works as 
a drug salesman at an Indian company.

India’s annual drug sales, estimated at $16 billion, may be small by the 
standards of the United States or Europe, but the market is attractive because 
it has been growing faster than 10 percent annually in recent years, placing it 
far ahead of developed markets in terms of growth.  It is also unusually 
competitive. Until about a decade ago, Indian intellectual-property law let 
manufacturers ignore drug patents — and thousands of manufacturers cropped up. 
Today India generally honours patents, but its medical marketplace retains its 
Wild West roots in the form of countless confusing brands and extreme price 
competition. As a government expert panel noted in a 2011 report, “The market 
is flooded by irrational, nonessential and even hazardous drugs that waste 
resources and compromise health.”

In this battle for sales, employees like Mr. Awasthi are the drug companies’ 
front-line foot soldiers.  In an email, Mr. Kadkol, the Abbott India spokesman, 
said, “We are deeply saddened to learn of Ashish Awasthi’s tragic demise,” 
describing him as “among the top performers in 2015.”

The ‘Perfect Life’

As multinationals like Abbott expand in India, they bring something powerfully 
attractive to the nation’s emerging middle class: jobs. The positions they 
offer become highly coveted, both for the prestige of working for a global 
company and because India’s economy — despite its 7.6 percent growth — still 
produces far too few jobs for the one million people who enter the work force 
each month.  This sets the stage for fierce competition for positions like 
these — and a desperation to retain them.  Mr. Awasthi embodied these 
ambitions. Hailing from a farming town about 400 miles northeast of Indore, he 
was one of the countless people who flock to India’s cities with hopes of 
climbing the economic and social ladder.

In December 2013, when Abbott hired him as a salesman, he felt he had won the 
lottery, said his 27-year-old widow, Anita Awasthi. He told her, “I can do 
everything for you now,” she recalled recently for visitors who had come to her 
home to offer their condolences.  His job was persuading doctors to use 
Abbott’s medicines for neurological diseases, and he was a disciplined 
salesman, according to a former boss, Ramchandra Tiwari. It is a gruelling job, 
Mr. Tiwari said, requiring aggressive efforts to catch doctors’ attention early 
in the morning or late in the evening.

Mr. Awasthi thrived, though. In 2015 he won a top salesman award. The young 
couple had made many close friends, his wife said, and maintained a busy social 
life going to movies and visiting area temples. She called theirs the “perfect 
life.    And they began to stretch financially. Mr. Awasthi bought a car — a 
sought-after symbol of arrival in the Indian middle class — and proudly carried 
a snapshot of it, garlanded with flowers. And he took out a loan to buy a 
one-bedroom apartment for about $20,000.   The purchases meant money was tight, 
Ms. Awasthi said. Her husband recently asked a friend to borrow about $70 to 
pay their 7-year-old daughter’s school fees.  Still, all was good, she said, 
until this June, when he got a new manager. According to his previous manager, 
Mr. Tiwari, the demands on the sales staff rapidly built. Mr. Tiwari described 
it as “inhuman and unnatural” pressure to sell.

The day he was found dead, Mr. Awasthi had been expected to attend a meeting 
with his new boss. Ms. Awasthi believes her husband — despite being a top 
performer — expected to lose his coveted job that day.

Camps for Check-ups

Mr. Gupta, the 37-year-old manager for neurology products in the northern city 
of Chandigarh, arrived at Abbott India from Solvay Pharma India when the two 
drug makers merged in 2011. Abbott India’s parent company acquired Solvay 
Pharmaceuticals, of Belgium, for $6.2 billion in 2010.  From the start, a 
contentious issue between Mr. Gupta and his managers was Abbott’s use of sales 
personnel to perform medical tests at health camps.

In India, where many people lack affordable care, these mass screenings have 
become a common way for drug makers to lift sales, according to current and 
former Abbott sales representatives and managers.   The industry-sponsored 
camps typically focus on chronic ailments such as diabetes, thyroid disorders, 
heart problems and lung disease. Sales personnel do the testing at no charge, 
and participating doctors get to increase their business by advertising free 
check-ups. In return, the doctors are expected to prescribe the drug maker’s 
product.

A February 2015 email from a marketing manager, Shrey Agrawal, telling sales 
managers that their representatives were supposed to attend a minimum of three 
neuropathy camps per quarter. (Some names and identifying information have been 
redacted.)   Some experts say these practices raise the prospect that people 
may be inappropriately diagnosed and could receive unnecessary treatment.

Abbott promotes its health camps nationwide as a core part of its “corporate 
social responsibility” program, which is intended partly to meet the Indian 
government’s requirement that companies contribute to the social good. “If it’s 
corporate social responsibility, then it shouldn’t be linked to the sales of 
the brand,” Mr. Gupta said.   Mr. Kadkol of Abbott India said, “Employees are 
not permitted to perform diagnostic tests.” The company denies that the purpose 
of the health camps is to have doctors use its drugs.

“Abbott’s procedures clearly state that disease awareness programs must not be 
conducted or provided or offered in exchange for an explicit or implicit 
understanding to purchase, order, recommend, prescribe or provide favourable 
treatment to any Abbott products,” Mr. Kadkol said in an email.

However, more than a dozen internal emails shared with The Times by Mr. Gupta 
suggest that Abbott viewed the camps as a sales tool and that the strategy came 
from Abbott management. In a February 2015 email, a group product manager 
informed the sales force that January sales of Surbex Star, a vitamin Abbott 
promotes to treat neuropathy in people with diabetes, were “way behind the 
expectations.”

“Now is the time to bounce back and surpass February target for Surbex Star,” 
the manager wrote. “Herein below are the 6 easy steps to conduct neuropathy 
camps.”

The manager did not return phone calls and emails seeking comment.

In another email from last year, an Abbott marketing manager told Mr. Gupta and 
other first-line sales managers that their representatives were supposed to do 
a minimum of three neuropathy camps per quarter and that they were behind in 
that goal.

“Camps will go a long way in promoting Surbex Star,” the marketing manager said 
in the email.

Several senior managers were copied on both emails.  Shrey Agrawal, who wrote 
that email but is no longer with Abbott, said in a telephone interview that 
“there is no direct link” between camps and drug sales. Asked how this tracked 
with his email about Surbex Star, he said he would respond by email. He never 
did.

In another email last year, an Abbott sales agent boasted that a neuropathy 
camp he had conducted was “a big success,” noting that 30 of the 40 patients 
tested positive, and that the doctor prescribed Surbex Star to all 30. He did 
not respond to requests for an interview.

A Dive Into Depression
As Mr. Gupta clashed with his bosses, he says, they began calling him and 
sending messages late at night and on Sundays, and he became depressed. After 
one particularly intense phone call, he grabbed a hot iron that his wife had 
just used and pushed it into his hand, searing his flesh and leaving a scar. He 
had thoughts of killing himself, he said, and saw a psychiatrist, who put him 
on an antidepressant and an antipsychotic.   Soon afterward, his bosses told 
him they wanted to transfer him 1,500 miles away, to the city of Chennai. He 
refused to go, he said, interpreting it as an effort to make him quit.

In an email to top leaders at Abbott India in August 2015, Mr. Gupta laid out 
his concerns. He told management that sales representatives were instructed to 
screen patients to increase sales.  As proof that the medical screening was 
happening, managers were instructing sales personnel to email photos of the 
tests being performed, Mr. Gupta explained — but with someone else posing as 
the tester, to conceal the representatives’ involvement. He said the practices 
violated Abbott’s code of ethics.   Mr. Gupta sent the allegations, and 
supporting documents, to the company’s office of ethics and compliance in India 
as well. The Times has reviewed the documents.

Last autumn, Mr. Gupta was fired. He was told he had lost the managers’ 
confidence, he said. Today he works for a hospital.

In response to allegations that the camps were improperly used to induce 
doctors to write prescriptions, Mr. Kadkol of Abbott India said, “That just 
doesn’t happen.” He noted that such camps were “not exclusive to a company,” 
adding, “They happen in many companies across many geographies.”    Regarding 
Mr. Gupta’s other claims, Mr. Kadkol said, “We don’t comment on the details of 
internal compliance investigations.”

Mr. Gupta’s former boss, Anup Ray, said in an interview that the purpose of the 
health camps was for doctors to prescribe Surbex Star. That made Mr. Gupta 
“uncomfortable,” Mr. Ray said. “I was also against it.”

Suspicions of Kickbacks
Mr. Khanna, the former Abbott manager who said he was fired after complaining 
about questionable sales made at discounted government rates, oversaw a team of 
neurology-medicine sales representatives in Lucknow, in northern India. Now 48, 
he had worked for 25 years for Abbott, Solvay and a company it acquired.

In 2013, he said, he began to notice the rapid rise in sales at the government 
discount. Suspicious that the sales were a form of a kickback to wholesalers, 
to induce more orders, he asked his sales staff and the wholesalers to produce 
original copies of the orders from government institutions, which they failed 
to do, Abbott emails show. Mr. Khanna stopped approving the transactions, he 
said, but another manager then began approving them.

Mr. Khanna wrote to Abbott’s ethics office in December 2013, laying out his 
concern that government purchasing rules were being violated. He said, “I am 
afraid if I will continue to resist these unethical practices anymore I may get 
transferred or may lose my job.”   On July 25, 2014, he says Abbott asked him 
to resign and accused him of a conflict of interest involving his wife. She had 
obtained a license the previous year to operate a wholesale drug business in 
case he left Abbott, where he felt increasingly insecure. Mr. Khanna said that 
opening a drug company would have violated Abbott’s rules but that his wife had 
not started a company.   He says he refused to resign. Abbott fired him.

Asked about Mr. Khanna’s allegations, Mr. Kadkol cited the company’s policy of 
not discussing individual cases or investigations into internal complaints.

Mr. Awasthi’s Final Days
Sitting on the floor of her tiny living room just days after her husband’s 
suicide, Ms. Awasthi recounted the final few weeks of her husband’s life.

“He told me, ‘The company is pressuring me,’” she said, wearing a pink sari, 
her two young children playing among the mourners. “I said, ‘Change jobs.’ He 
said, ‘How will I get another job?’”

Work pressure built quickly in June after the new boss, Inder Kumar, took over 
managing Mr. Awasthi’s sales team. His previous manager, Mr. Tiwari, had been 
asked to transfer to a city in southern India, more than 1,000 miles away from 
Indore. He declined the transfer and lost his job.  According to two former 
employees of the new manager, he could be a tough boss. One of them, Mayank 
Pandey, said he felt so desperate to meet sales targets that he bribed doctors 
with his own cash to get them to prescribe Abbott drugs. Mr. Pandey quit Abbott 
this year, describing himself as “mentally broken.”

Mr. Kumar declined requests for interviews, referring questions to Mr. Kadkol, 
Abbott India’s public affairs director, who cited the company’s policy not to 
comment on individual employees.

In general, Mr. Kadkol said, “retaliatory or denigrating behaviour of any kind 
is not accepted” at Abbott, which encourages an environment “devoid of any 
harassment or undue pressure.” He said any suggestion that Mr. Awasthi “was 
singled out for poor performance is without merit.”

Ms. Awasthi said Mr. Kumar had summoned her husband to a Monday meeting. The 
day before, she says, Mr. Awasthi was unusually quiet. He swept their 
apartment, bathed both of the children and fed them. Then he napped by his 
wife’s side. At about 6 p.m., he went out, leaving behind his cell phone and 
wallet.

Police found his body the next morning along the railroad track.

After Mr. Awasthi’s death, Abbott gave his family a check for 345,000 rupees, 
about $5,000, which included his salary and allowances for July, various 
reimbursements, as well as a “gratuity.” Though Ms. Awasthi does not work and 
needs money, she has refused to cash it.
“He died because of them,” she said. “They must take responsibility.”

Geeta Anand reported from Indore, India, and from New Delhi and Mumbai, and 
Frederik Joelving from Copenhagen. Suhasini Raj contributed reporting from New 
Delhi.

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