Six years ago when Mayank Sinha (name changed) was 24-years-old and had spent a few months working as a pharmaceutical representative in a pharmaceutical company, he almost drove his motorcycle under a truck.

“I didn’t want to live,” said Sinha, sitting in his one-room rented flat in the Rohini area of Delhi one morning in July 2017. “It was the last week of that month and I was finding it hard to meet the sales target that the company had given me.”

That morning Sinha was told by the company that he would be fired if he did not meet his target. His senior colleague who was riding pillion stopped him from committing suicide. The next day, Sinha was fired. Since then, he has worked at two other pharmaceutical companies and has found only greater pressure to meet targets.

Sinha and other representatives like him are on the frontlines of the pharmaceuticals business. Companies hire representatives to promote sales of their medicines. The job requires a pharmaceutical or medical representative to regularly meet doctors and tell them about the company’s medicines and their advertised benefits in order to persuade doctors to prescribe the company’s medicines. While some companies prefer representatives to have a Bachelor’s or Master’s degrees in pharmacy or sales and marketing, some are ready to hire any smart graduate student who can learn on the job. The latter, like Sinha, are hired at lower salaries.

Work pressures are significant. In mid-July 2016, 27-year-old Ashish Awasthi, a pharmaceutical representative in Indore, rode his motorcycle to a railway track and jumped in front of a train. “I am going to commit suicide because I can’t meet my company’s sales target and my company is pressuring me,” read the note that was found in his pocket, the New York Times had reported at the time.

Sanjeev Khandelwal, secretary of the Federation of Medical and Sales Representatives’ Associations of India, said that he often hears of medical representatives dying in road accidents. “Eighty percent of these accidents happen in the last week of a month,” he said, implying that these were work-pressure driven suicides. “Unimaginable targets are fixed by companies.”

Landing the job

Sinha grew up in Benaras where he lived in a small house with a tin roof with his pharmacist father who dispensed drugs to patients in a doctor’s clinic, home-maker mother, a younger brother and a younger sister. To pay his school fees, Sinha used to spend his early mornings selling tea in a market. After completing graduation, his first formal job was as an operator at a Public Call Office. He then worked at a water tank manufacturing factory, and then at one that made electric motors. But none of these jobs paid him enough to support his family.

Sinha moved to Delhi for better prospects. He got a job in a call center, which paid just slightly more than what he was earning in Benaras. One day after work, while he was going home on a bus, he got talking with a man who was a medical representative. A few days later, the man called Sinha and introduced him to the executives at the pharmaceutical company he worked for.

In the last week of July, Sinha was desperate to meet his monthly target of Rs 75,000 worth of sales. The company sets annual sale targets for medical representatives and breaks them into quarterly and monthly targets. These targets are increased every year.

If the representatives fail to achieve targets, they get warnings, their travel and living allowances are cut and their their salaries might be withheld. If a representative falls short of targets two or three times, he is transferred to a new city or fired from the job.

“That we will be fired is a constant threat,” said Sinha. “We live very insecure lives.”

Pharmaceutical representatives marched to Parliament in November 2016 protesting their working conditions. (Photo: Federation of Medical and Sales Representatives' Association of India)

One night that week, Sinha woke up gasping for breath. He walked for a bit on his terrace to calm himself down. “This sales pressure is not letting me sleep,” he said.

Sinha’s mornings begin with typing out a list of doctors he plans to meet that day as sending them to a Whatsapp group of his team, which include three other medical representatives and their team leader from the company. All of them are responsible to promote company’s sales in Rohini area.

On that July morning, Sinha quickly showered, prayed and ate breakfast. He put his diary, a pen, a blue company brochure and samples of medicines in his bag, and left home by 10 am.

Sinha was tense because he had met only 60% of his target and there were only a few days to the end of the month. The first doctor he met that day runs a private clinic inside a residential complex in Delhi’s Rohini area. Sinha introduced himself and then proceeded to tell her about his company’s medicines with help from the blue brochure.

Part of Sinha’s job is to remind and cajole the doctor into prescribing these drugs regularly. “Ma’am please see if you can prescribe these medicines,” Sinha requested the doctor.

“I will see,” she replied, not giving Sinha any assurances.

One of the ways Sinha figures out whether, how much, and how frequently a doctor prescribes his medicines is by checking with the nearby chemist shops where most patients buy the prescribed medicines. Chemists keep a track of how much of a particular medicine they are selling. They are also aware if a particular doctor is prescribing a particular medicine.

Sinha has to work on 120 doctors in Rohini. He meets them depending on their availability, which could be anytime between 10am and 11:30pm.

“What makes this job difficult is the fierce competition among companies to sell their drugs,” said Sinha.

Most of the drugs that Sinha promotes are to treat cardiovascular problems. A senior manager of another multinational pharmaceutical company who did not want to be identified said that cardiovascular diseases are one of the most lucrative segments for pharmaceutical companies because these drugs are priced high and patients have to take them for life. In 2015, cardiovascular drugs made up about 13% of the Indian pharmaceutical market that was worth $20 billion.

“I imagine that there would be very few companies who wouldn’t want to get into this sector,” said the manager.

Medical representatives from, different companies who are responsible for sales from the same region and promote drugs for same health problems, tend to meet the same doctors. And each of these medical representatives tries to convince that doctor to prescribe their drugs. “It is challenging to first get a doctor to prescribe your medicine and then to ensure that she or he keeps prescribing that medicine,” said Sinha. “Sometimes a doctor stops prescribing your drugs and starts writing drugs of some other company, and doesn’t tell you why.”

Sinha tries to get doctors to prescribe the more expensive of his company’s medicines so that he can achieve his target faster.

Quid pro quo

The waiting area outside the cabin of the second doctor that Sinha met was packed with medical representatives from other companies. Sinha repeated his presentation of medicines for this doctor. The doctor seemed unenthusiastic.

Sinha asked the doctor whether he could do anything for him.

“The doctor gave me a booklet and asked me to get its 10,000 copies printed for him, and then he will see what he can do,” Sinha recalled. The booklet had promotional information about that doctor and other doctors in Rohini. He did not tell Sinha why he wanted the copies.

Many doctors have asked Sinha for favours in return for prescriptions. These favours range from asking Sinha for cash, electric appliances, kitchen utensils, movie tickets, plane tickets, fancy cell phones, cell phone account recharges and even cars. During the initial days after Prime Minister Narendra Modi announced the demonetisation of Rs 100 and Rs 500 notes, a doctor had asked Sinha to get him Rs 30,000 in new notes. Sinha stood in long queues outside ATMs to withdraw the money from his bank account. His company reimbursed him.

Sometimes pharmaceutical companies have sent Sinha out to meet doctors armed with gifts like packets of sugar, rice and flour, and plane tickets to conference tours abroad. “Only five out of 100 doctors refuse such gifts or don’t demand favours,” said Sinha.

The Medical Council of India regulations prohibits doctors from accepting gifts worth more than Rs 1,000 from pharmaceutical companies. If caught, the doctors’ names can be removed from the Indian Medical Register or State Medical Register for between three months and more than one year.

To check whether doctors he visited were prescribing his company’s medicines, Sinha visited a chemist in Rohini that day. He asked the chemist if she had received prescriptions for drugs in his blue company brochure. The chemist said that she had stocks of those medicines but had not got any prescriptions and so had not sold them yet. Sinha requested him to order more. The chemist offered to order more if the company had a scheme by which she can get some free strips of the medicines. Chemists make extra money by selling the free strips. Sinha apologetically said that his company does not offer schemes.

“In that case, I will order only after I get prescriptions,” said the chemist.

A pharmacy in Delhi.(Photo: Klaus Nahr/Flickr)

Another chemist asks Sinha to buy the drugs for him. The chemist does not want to lose money if patients do not come to him with prescriptions for that drug. Most chemists do not buy a drug unless they see a steady stream of prescriptions. A few months ago, when Sinha was Rs 20,000 short of meeting sales target of that month, he spent his money to buy drugs worth that amount from a stockist that supplies his company’s drugs, and gave them to a few chemists. He will get the money back only if the chemists sell those drugs. “My company doesn’t know this but I have to do such things to meet my target and to save the job,” he said.

Meet, repeat

On most days Sinha reports his progress on WhatsApp. On that day, however, he rushed to attend a meeting that his team leader had called at 2pm. The meeting went on for two hours and Sinha came out looking agitated. A colleague was given a warning that he would be fired if he did not meet his target.

“You cannot throw people when you want,” Sinha exclaimed, gritting his teeth. “ The poor guy has a family. Where will he go?”

He left to meet more doctors and chemists.

Sinha’s wife Madhu and their seven-year-old daughter Srishti (names changed) live in Benaras with his parents. Madhu and Shrishti come to Delhi during summers and were here with him at the end of July. In a few days, they would go back for Benaras. He longs to live with them in Delhi but his salary of Rs 20,000 does not allow that. He needs to pay rent, send money back home, pay his daughter’s school fee, and pay loan instalments for his motorcycle, laptop, and the house in Benaras. Sometimes, thoughts of suicide push their way into his mind again but he stops himself for fear of what will happen to his family. “They depend on me,” he said. “They will collapse if I die.”

That night Sinha went to bed at around 11:30pm. In a few hours, he felt short of breath, and woke up. He quietly got out of the bed, picked his way through the room and went to walk on the terrace.