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 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 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 grueling 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 Checkups
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 companyacquired 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 checkups. In return, the doctors are expected to prescribe the drug maker’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,” 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 favorable 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 behavior 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 cellphone 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.”