Leaving his wife and two young children home on a recent Sunday, a 27-year-old salesman for Abbott Laboratories’ operations in India — one of the US healthcare 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 healthcare giant.
Illustration: Yusha
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 doctors’ offices or as community events.
Sales personnel who perform screening tests could be accused of practicing medicine without a license, a criminal offense, said Jayshree Mehta, president of the Medical Council of India, the nation’s medical regulatory agency.
Indian medical ethics regulations also prohibit quid pro quo, Mehta said.
Abbott India 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.
However, 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 said tried to resist, 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 (US$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, said 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 US$16 billion, may be small by the standards of the US 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 honors 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 said 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 e-mail, Kadkol said: “We are deeply saddened to learn of Ashish Awasthi’s tragic demise,” describing him as “among the top performers in 2015.”
‘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 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 645km 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 Anita Awasthi, his 27-year-old widow.
He told her: “I can do everything for you now,” she said to 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, said a former boss, Ramchandra Tiwari.
It is a grueling job, requiring aggressive efforts to catch doctors’ attention early in the morning or late in the evening, Tiwari said.
Ashish Awasthi thrived, though. Last year, he won a top salesman award.
The young couple made many close friend sand maintained a busy social life, going to movies and visiting area temples, his wife said.
She called theirs the “perfect life.”
However, 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.
He took out a loan to buy a one-bedroom apartment for about US$20,000.
The purchases meant money was tight, Anita Awasthi said.
Her husband recently asked a friend to lend him about US$70 to pay for their seven-year-old daughter’s school fees.
Still, all was good, she said, until June, when he got a new manager.
The demands on the sales staff rapidly built, Tiwari said, describing it as an “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.
CAMP 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 Belgium-based Solvay Pharmaceuticals for US$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, current and former Abbott sales representatives and managers said.
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.
“Employees are not permitted to perform diagnostic tests,” Kadkol said.
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 favorable treatment to any Abbott products,” Kadkol said in an e-mail.
However, more than a dozen internal e-mails 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 an e-mail in February last year, 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 telephone calls and e-mails seeking comment.
In another e-mail from last year, an Abbott marketing manager told 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 e-mail.
Several senior managers were copied on both e-mails.
Shrey Agrawal, who wrote that e-mail, 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 e-mail about Surbex Star, he said he would respond by e-mail.
He never did.
In another e-mail last year, an Abbott sales agent boasted that a neuropathy camp he had conducted was “a big success,” saying 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.
DIVE INTO DEPRESSION
Gupta said that as he clashed with his bosses, they began calling him and sending messages late at night and on Sundays, and he became depressed.
After one particularly intense telephone 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 said he had thoughts of killing himself and saw a psychiatrist, who put him on an antidepressant and an antipsychotic.
Soon afterward, his bosses told him they wanted to transfer him more than 2,400km away — to the city of Chennai.
He refused to go, interpreting it as an effort to make him quit.
In an e-mail to top leaders at Abbott India in August last year, 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 e-mail photographs of the tests being performed, Gupta said — but with someone else posing as the tester, to conceal the representatives’ involvement.
He said the practices violated Abbott’s code of ethics.
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.
In autumn last year, 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, Kadkol said: “That just doesn’t happen.”
He said that such camps were “not exclusive to a company.”
“They happen in many companies across many geographies,” Gupta added.
Regarding Gupta’s other claims, Kadkol said: “We don’t comment on the details of internal compliance investigations.”
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 Gupta “uncomfortable,” Ray said.
“I was also against it,” Ray said.
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.
He said that in 2013, 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 e-mails show.
Khanna said he stopped approving the transactions, but another manager then began approving them.
Khanna wrote to Abbott’s ethics office in December 2013, laying out his concern that government purchasing rules were being violated.
“I am afraid if I will continue to resist these unethical practices anymore I may get transferred or may lose my job,” he said.
On July 25, 2014, Abbott asked him to resign and accused him of a conflict of interest involving his wife, he said.
She had obtained a license the previous year to operate a wholesale drug business in case he left Abbott, where he felt increasingly insecure.
Khanna said that opening a drug company would have violated Abbott’s rules, but that his wife had not started a company.
He said he refused to resign.
Abbott fired him.
Asked about Khanna’s allegations, Kadkol cited the company’s policy of not discussing individual cases or investigations into internal complaints.
FINAL DAYS
Sitting on the floor of her tiny living room just days after her husband’s suicide, Anita 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 Awasthi’s sales team. His previous manager, Tiwari, had been asked to transfer to a city in southern India, more than 1,600km 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.
Pandey quit Abbott this year, describing himself as “mentally broken.”
Kumar declined requests for interviews, referring questions to Kadkol, who cited the company’s policy not to comment on individual employees.
In general, “retaliatory or denigrating behavior of any kind is not accepted” at Abbott, Kadkol said, which encourages an environment “devoid of any harassment or undue pressure.”
He said any suggestion that Awasthi “was singled out for poor performance is without merit.”
Anita Awasthi said Kumar had summoned her husband to a Monday meeting.
The day before the meeting, Ashish Awasthi was unusually quiet, she said.
He swept their apartment, bathed both of the children and fed them. Then he napped by his wife’s side. At about 6pm, he went out, leaving behind his cellphone and wallet.
Police found his body the next morning along the railroad track.
After Ashish Awasthi’s death, Abbott gave his family a check for 345,000 rupees, which included his salary and allowances for last month, various reimbursements, as well as a “gratuity.”
Though Anita Awasthi does not work and needs money, she has refused to cash it.
“He died because of them,” she said. “They must take responsibility.”
Additional reporting by Suhasini Raj
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