By GEETA ANAND and FREDERIK JOELVING
Leaving his wife and two young children home on a recent Sunday, a 27-year-old salesperson 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 licence, 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, 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. 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 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 salesperson 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 per cent 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 Awasthi are the drug companies' front-line foot soldiers.
In an email, Kadkol, the Abbott India spokesperson, 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 per cent growth — still produces far too few jobs for the 1 million people who enter the workforce each month.
This sets the stage for fierce competition for positions like these — and a desperation to retain them.
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 salesperson, 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 salesperson, according to a former boss, Ramchandra Tiwari. It is a gruelling job, Tiwari said, requiring aggressive efforts to catch doctors' attention early in the morning or late in the evening.
Ashish Awasthi thrived, though. In 2015 he won a top salesperson 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. Ashish 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, Anita 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, Tiwari, the demands on the sales staff rapidly built. Tiwari described it as "inhuman and unnatural" pressure to sell.
The day he was found dead, Ashish Awasthi had been expected to attend a meeting with his new boss. Anita Awasthi believes her husband — despite being a top performer — expected to lose his coveted job that day.
Camps for Checkups
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 drugmakers 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 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 drugmakers 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 checkups. In return, the doctors are expected to prescribe the drugmaker's product.
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," Gupta said.
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," Kadkol said in an email.
However, more than a dozen internal emails shared with The Times by 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."
New York Times