|Year : 2021 | Volume
| Issue : 1 | Page : 1-10
Conflict of interest in physician–pharmaceutical industry interactions: Possible interventions in Nigeria medical practice
Ijeoma Victoria Ezeome
Department of Obstetrics & Gynaecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu; Department of Obstetrics & Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu
|Date of Submission||07-May-2020|
|Date of Decision||29-Jun-2020|
|Date of Acceptance||11-Sep-2020|
|Date of Web Publication||21-Oct-2020|
Ijeoma Victoria Ezeome
Department of Obstetrics & Gynaecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, P.M.B. 01129, Enugu.
Source of Support: None, Conflict of Interest: None
Collaboration between physicians and the pharmaceutical, medical device, and biotechnology industries results in the development of products of great benefit to the public. However, when these interactions negatively influence professional judgments at the expense of the goals of medicine, it becomes a cause of great concern. The objective of this simple review was to bring to the fore the conflicts that exist between these two important areas of patient care and to suggest ways to prevent it in Nigeria. A literature search in the PubMed, Medline, and Web of Science databases was done using the terms conflict of interest, physician, pharmaceutical, medical practice, detailing, biomedical research, bioethics, prescribing pattern, singly or in combination to identify relevant articles. The results are arranged based on the themes of related published articles. This review shows that interactions between physicians and the pharmaceutical industry have multiple areas of conflict ranging from reduction in the quality of patient care, loss of objectivity in professional education, scientific integrity, and the public’s trust in medicine. Interaction between pharmaceutical sales representatives (PSRs) and physicians commonly occur in Nigeria, affecting prescribing behavior. There is no specific regulation in place to protect against ensuing conflicts. There is a need to put in place educational programs to increase awareness among physicians of the effects of such interactions, while also instituting and implementing stringent policies curtailing physician–pharmaceutical industry and PSR relationships.
Keywords: Conflict of interest, medical practice, Nigeria, pharmaceutical, physician
|How to cite this article:|
Ezeome IV. Conflict of interest in physician–pharmaceutical industry interactions: Possible interventions in Nigeria medical practice. Int J Med Health Dev 2021;26:1-10
|How to cite this URL:|
Ezeome IV. Conflict of interest in physician–pharmaceutical industry interactions: Possible interventions in Nigeria medical practice. Int J Med Health Dev [serial online] 2021 [cited 2021 Jan 28];26:1-10. Available from: https://www.ijmhdev.com/text.asp?2021/26/1/1/298781
| Introduction|| |
A conflict of interest (COI) is a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest. COIs may be financial or nonfinancial. However, financial COI seems to be more discussed, not because it is more corrupting than other interests but rather due to its objectivity and quantifiable nature.
The three key elements in a COI include the primary interest, secondary interest, and the conflict itself. The primary interest concerned depends on professional activity. Primary interests may include patient welfare, protecting research integrity, and upholding the quality of medical education. Secondary interests may include financial gain, desire for professional advancement, recognition for personal achievement, and favors to friends and family or to students and colleagues or other interests that may be legitimate or illegitimate. There is nothing wrong with secondary interests but become unacceptable when their weight becomes greater than the primary interest in professional decision-making. A researcher’s desire for published papers needed for professional advancement should be subordinate to presenting scientific evidence in an unbiased manner in publications and presentations. The conflict itself is the third key element. The primary interest need not be compromised for a conflict to exist. It is rather the existence of a set of circumstances or relationships that create or increase the risk that the primary interests will be neglected as a result of the pursuit of secondary interests. The fact that actual influence may not occur does not rule out the existence of a COI.
The medical profession has always had the welfare of the patient as its primary interest according to the Physician Oath dating as far back as the times of Hippocrates. Many studies have shown that interactions between physicians and PSRs do affect physician behavior. This interaction extends from supporting research and medical education to providing up-to-date details and educational material targeted at patients and doctors. Interactions between PSRs and physicians is common in Nigeria.
Although many physicians regard PSR visits as an efficient source of information on current drugs and devices not provided by other parts of the healthcare system, clarification on the extent of the relationship through policies that keep these interactions within ethical boundaries is urgently needed to adhere to the goals of medicine, as well as maintain public trust.
The aim of this simple review was to discuss the conflicts in the relationship between physicians and the pharmaceutical industry, and is organized along the most recurring themes in the analyzed literature, which include drug promotional methods by the pharmaceutical industry; pharmaceutical industry gifting, physician perception, and attitude to physician–pharmaceutical industry interaction; patient and public perception of physician–pharmaceutical industry interaction; as well as the effect on medical practice and impact on society. In addition, the review findings are applied to the Nigerian situation and solutions proffered.
| Materials and Methods|| |
Information was obtained through an extensive literature search in PubMed, Medline, and Web of Science using the keywords conflict of interest, physician, pharmaceutical, medical practice, detailing, biomedical research, bioethics, and drug prescription, singly or in combination. In total, 200 articles were initially obtained. Criteria for selection were articles published (cross-sectional, qualitative, narrative, and systematic reviews) up to and including June 19, 2020, written in English language that discussed about COI in biomedical research, ethics of physician–pharmaceutical industry relationships, drug promotional methods, pharmaceutical industry gift-giving and acceptance by physicians, as well as the impact of physician–pharmaceutical industry interaction on medical practice and society in general. Articles that were not focused on the above aspects of interaction were excluded leaving 80 articles for inclusion in the review process. The advantages and disadvantages of such interactions were noted and weighed into the discussion with reference to medical practice in Nigeria.
| Results|| |
Drug promotional methods by the pharmaceutical industry
According to World Health Organization’s (WHO) criteria for medicinal drug promotion, promotion refers to all the informational and persuasive activities of manufacturers and distributors, the effect of which is to induce the prescription, supply, purchase, and/or use of medicinal drugs. Many big pharmaceutical companies think that doctors with huge prescribing power are the gateway to eventual drug sales. So, they spend a huge budget targeting the prescribers and promoting drugs through advertising, gift-giving, supporting medically related activities, and sometimes financially. On average, pharmaceutical companies spend 20% or more of their sales on marketing which make them a lot of money and hence they have little incentive to stop these tactics. The global pharmaceutical market was valued at US$1.25 trillion in 2019, a significant increase from 2001 when it was valued at US$390 billion.
Detailing is a one-on-one marketing technique used by pharmaceutical companies to educate physicians on their products with the hope that they prescribe these products. It is the foremost pharmaceutical marketing technique. The fall-out of this, however, is that they take up the time that should be used to attend to patients. The physicians are given current literature documents on the products, and drug information may also be provided via visual aids, flip charts, or audio-visuals. They also collect physician contact information and regularly contact them via social media to remind them of the probable superiority of their products in comparison to others in the market. A current variation from this traditional method is the e-detailing technique in which pharmaceutical representatives use the internet to build similar relationships with physicians using social networking and other web technologies.
Drug promotional advertisements (DPAs) form another major marketing technique of pharmaceutical companies for promoting their products and disseminating ambiguous drug information which can affect the prescribing pattern of physicians. Drug information includes product characteristics and various marketing claims with references in support to increase its credibility and authenticity. A study which critically analyzed the claims and authenticity in Indian DPAs found that out of 160 references given in support of claims, 49 (30%) of references were irretrievable and, of the 111 (70%) retrievable references, 92 (83%) references were found valid, showing that information provided in the DPAs was biased, incomplete, unauthentic, and unreliable with references exhibiting questionable credibility. Similarly, a Nepal study reported that while therapeutic indication was mentioned in 87.88% of promotional material, information on side effects, drug interactions, and use in pregnancy and lactation were lacking in the majority of promotional materials. Additionally, a Pakistani study confirmed that promotional drug advertisements were adjudged misleading and exaggerated. These findings are similar to those in developed nations which despite their much more established regulatory apparatus continue to be affected by the greed of the pharmaceutical industry in connivance with members of the medical community. Critical review of drug promotional literature can make drug prescribing more effective. If drug promotional literature fulfills all WHO guidelines, it can make promotion ethical and rational.
Another promotional method is gift-giving in the form of free drug samples, small stationery, travel to conferences and educational events, and cash., A Bangladesh study reported the use of gifts in different forms, such as desktop items (pen, pad, paperweight, diary), personal use goods (laptop, watch, clothes, jewelry), household goods (crockery, air conditioner, furniture), food items, and cash. Similar findings were obtained among Nigerian physicians where meals and cheap gifts were the most common items offered.
Pharmaceutical industry gift-giving
The pharmaceutical industry contributes to the welfare of patients through sponsorship of social activities and support of educational and research undertakings. They are involved in supporting researchers as they work toward gaining new knowledge for the benefit of patients and society. However, a drug company’s primary interest is to maximize sales of its product for profit, not the health of patients. This interest is opposed to that of the medical profession. The involvement of physicians as key decision-makers is the reason that they are the focus of most promotional efforts of pharmaceutical companies. The interactions occur at different levels.
Physicians are often supplied with substantial amounts of free products for direct assessment of the effectiveness of a drug, which they can then dispense to patients at no cost. Because most physicians’ offices are not provided samples of generic, less-expensive medicines, there is a dilemma. Patients are forced to use more expensive branded products despite the availability of generic ones.,
In addition to the documents containing product information, these PSR also give out company products such as pens, diaries, stethoscopes, and other medical practice devices. The gifts sometimes can become lavish to include those unassociated with professional practice such as home laptops, payment for family holidays,, and sometimes direct payment for using particular products.
Sponsorship of continuing medical education, professional meetings, and conferences
Continuing medical education (CME) is an important component of good clinical practice worldwide. It enables medical practitioners and academic physicians to keep abreast of current management of patients and new innovations in practice. In Nigeria, all physicians are required to submit a stipulated unit of CME to maintain licensure. The industry through their PSRs pays for sponsorship of CME lectures as well as attendance to professional conferences for the whole faculty and specific physicians. They sponsor meals at such meetings and conferences while advertising their products. This relationship has been shown to create conflicts of interest, potentially leading to commercial influences on patient care. The cost implication to the industry in our country has not been studied. However, pharmaceutical industries in the USA fund up to 60% of accredited CME costs.
Physicians are responsible for research into new drugs and devices for societal improvement and treatment of various diseases. The pharmaceutical industry employs them to take part in or lead industry-funded research. Sometimes, physicians work as consultants on pharmaceutical boards as advisers and present results of research into industrial products., Studies have shown that research funded by drug companies is more likely to have outcomes that favor the sponsor’s product than research funded by other sources. The result may be due to inappropriate comparators or publication bias. The increasing influence and control by the pharmaceutical industry brings to attention existing gaps in the current protection of the public interest with regard to the conduct and reporting of clinical trials. More needs to be done to ensure that the academia put patients’ and participants’ interests ahead of corporate interests and that society reestablishes its control over the health research agenda.
The pharmaceutical industry maintains personal relationships with physicians by remembering their birthdays and sending goodwill messages on important national holidays. The industry also may provide hospitality in various forms for physicians who have been good prescribers of their products.,
Physician perception of physician–pharmaceutical interactions
It is common knowledge that the primary duty of physicians is to manage their patients in a way that will achieve the patients’ best interest and avoiding any harm, while respecting their autonomy. These objectives of optimal care have hugely been supported by the pharmaceutical industry through the provision of new medications, innovative medical devices, and enabling environment for conducting clinical trials to further the goals of medicine. Despite these laudable advantages, commercialization of medicine has also crept into the relationship between the physicians and the pharmaceutical industry.
Many studies confirm the interaction between physicians and pharmaceutical industry representatives. Fadare et al. reported that 87.5% of 176 Nigerian physician respondents were visited by PSRs for drug promotional activities over the previous three months, while 94.5% of Peruvian physicians had on-going encounters with PSR as reported by De Ferrari et al.. A systematic review by Fickweiler et al. showed that interactions between physicians and PSRs are a common occurrence. In two German studies, 84 and 77% of physician respondents reported weekly physician–PSR interactions with 19% reporting daily interactions., In the same vein, 62.9% of Indian physicians also indicated between once weekly to twice monthly interactions with PSRs.
The perception of physicians regarding the importance of PSR interactions as sources of education vary. Some studies show physicians’ support for these interactions as important sources of education and funding., 43% of doctors believed that they received adequate and accurate information from PSRs frequently or always in a German study, while a qualitative study among Egyptian physicians also indicated that the PSRs have the good product knowledge and help physicians with the pharmacology of the products. However, a number of other studies found negative reactions to the information from PSR during interactions with physicians. A cross-sectional study among German physicians found that 102 of 160 physician respondents stated that they only occasionally, rarely, or never receive adequate information from PSR. Similarly, about 69.1% of Indian doctors in a cross-sectional study think that medical representatives exaggerate the benefits of medicines and downplay their risks and contraindications.
Physicians noted that common gifts from PSRs consist of stationary, medical samples, journals, invitation to dinners, and payment for conferences and workshops. Bahammam et al. found that more than half of the physician study participants (60.3 and 55.3%) received stationery and industry-sponsored CME events, respectively, within the workplace from one to three times per month. Similar gift patterns have been reported in several other studies.,,
Most physicians reported that their prescribing behavior was not affected by the received gifts but believe that the gifts affected the prescribing pattern of colleagues. However, many studies have been published confirming industry influence on objectives and behaviors of physicians.,,, Many physicians frequently do not recognize that their decisions have been affected by commercial gifts and services and may, in fact, deny or minimize such influence.
Patients and public perception of physician–pharmaceutical industry interactions
Concerns are rife that physician–pharmaceutical industry interaction could lead to an increase in the cost of patient care through inappropriate prescribing or use of medical devices. This ultimately undermines patient–physician relationship, leading to mistrust of the medical profession. Patients’ and general public perception about physician–pharmaceutical industry interaction is important as it helps with designing appropriate interventions. Studies indicate that patients are generally aware of the promotional and marketing activities of pharmaceutical companies to physicians,, although they have low awareness of physician receipt of gifts. An Australian study found that 76% of 906 patients in the waiting rooms of three general practices in 2007 were unaware their physicians received gifts, and only 3 to 12% of 192 adults admitted to outpatient clinics were aware that their physicians could accept gifts greater than $100 in value, give lectures for drug companies, conduct research for drug companies, or accept drug company meals. The rate of awareness of received gifts was commonest with drug samples and gifts with possible benefits to the patients., Patients’ perception on the effect of these interactions on quality of care and prescription behavior is generally negative. 70% out of 486 participants in the waiting rooms of two-family practice centers believed that gifts sometimes or frequently influenced a physician’s prescribing of medication. 49% out of 192 participants in outpatient clinics agreed that gifts or meals influenced the physician’s prescribing behaviors. Furthermore, 43% believed that physicians who accepted small gifts in return for listening to a pharmaceutical representative’s presentation on a particular drug would be more likely to prescribe that medication., 69% out of 200 patients visiting a general medical office in 1995 thought that some doctors might be influenced to enroll patients in research just for the fee. The majority of patients also believe that gift acceptance by physicians from pharmaceutical representatives increased the cost of care. In a Turkish study, 55% out of 584 patients admitted to primary health care believed that promotion expenditures increased the cost of medications. Only 31.6 and 1.2% of the general public in 2007 believed that gifts had no effect and decreased cost, respectively. The attitude of respondents to gifts not relevant to medical practice was that they are inappropriate, and respondents would choose doctors who do not see PSR over those who do., The majority of patients supported physician disclosure of conflicts of interest related to their care, Preferred disclosure methods reported ranged from simple literature, verbal, and consulting room posters, though some respondents had concerns that verbal disclosure may distract physicians from patient care or take up time needed for consultation. Patients’ suggestions on ways of limiting these conflicts include regulating or outright forbidding promotional activities aimed at physicians.
Impact of physician–pharmaceutical industry interaction on medical practice
Information about indications and dosages of drugs are brought to the doorstep of the physicians, including new drugs and devices. Biomedical research that leads to development of new drugs and devices is expensive and industry provides the necessary financial support needed to carry out the studies. One study found that pharmaceutical representatives provide information about medication indications and dosages to a relatively high percentage of physicians. Similarly, interaction with the device industry has contributed to important technological and medical care advances., It has also allowed physicians to become more familiar with, and use the latest technology when caring for their patients, which has led to beneficial effects on patient outcome.,
Despite the above positive impacts, the relationship between physicians and pharmaceutical/device industry is complex in that the industry makes its living from the prescriptions that physicians write, and the devices and services patients purchase through their recommendations or use. An important part of what industry is buying with its money is professional recognition and the endorsement it implies from leaders in the field. Despite this knowledge, physicians receive gifts and support in different forms from this same industry. One is therefore not surprised that this relationship could influence their conduct to the advantage of the pharmaceutical industry at the expense of their primary interest: the patient and integrity of the medical profession.
COI results when physician roles appear to or are influenced by motives other than those which are in the very best interest of their patients, thereby violating not only the patient’s interests but also the standards of scientific integrity.
While large cash payments and lavish gifts to physicians by pharmaceutical industry are commonly seen to be of great concern in its effect on physician integrity and negative influence on the healthcare system, there is an argument by many that the little gifts given by most pharmaceutical representatives do not significantly affect the prescribing pattern of physicians. Physicians believe that their colleagues are more susceptible to pharmaceutical industry marketing strategies than themselves. The majority of the physicians do not believe that they are affected by pharmaceutical industry and PSR interactions. They often get offended by the suggestion that their practice is influenced by gifts, and fail to see the conflict created by receiving hospitality or apparently trivial items from the pharmaceutical industry. There is a strong view that scientific training and medical professionalism protect against any bias towards companies providing these items, and that succumbing to bias or influence is due to lack of personal integrity. Research has however shown this to be untrue since behavior is not entirely rational and individuals are not always conscious of their motives for action., The ability to remain objective in the face of receiving gifts has been questioned. A tendency for nonrational prescribing, more favorable attitudes towards industry representatives, preference for newer, more expensive drugs, and an inability to identify incorrect claims about medications was reported by Wazana. Frequency of contact and gift acceptance was found to determine how much influence it had on physician behavior, irrespective of the value of the gift., This culture of gift-giving and acceptance breeds a long term sense of entitlement which leads to a feeling of indebtedness on the side of the doctors, and is repaid by the support of the patron’s drugs, even at cost of direct conflict with physician’s primary obligation to the patient. There have been instances of physicians prescribing drugs that are less effective or with complicated dosing regimen for patients despite the availability of evidence-based alternatives. This may be as a result of physician reciprocity to gift-giving.
Patients and the public have a right to trust that physicians will act and make decisions in ways that are consistent with the primary interest of patient welfare. However, a systematic review shows that the awareness of patients was low for physician’s receipt of personal gifts but relatively higher for office use gifts and educational materials. This is because educational materials and office use gifts are provided during office hours but personal gifts may be out of office hours. This is why some have insisted that physician disclosure to patients and the public is important.
| Discussion|| |
As a response to the resulting conflicts, many developed countries including the USA, Canada, and Australia established regulatory and advisory bodies which have instituted guidelines for identifying, disclosing, and managing potential COI.,, There is a mandatory requirement for disclosures of financial interactions between the pharmaceutical industry and physicians, medical organizations, and academic medical centers. Representatives’ statements must be accurate and complete and must not be misleading, either directly or by implication. The new code of the Pharmaceutical Research and Manufacturers of America (PhRMA), also discourages pharmaceutical companies from giving physicians gifts that do not carry benefits to patients. How this has led to behavioral change is yet to be determined, since gifting to physicians remain common and often involve physicians who play a role in formulating treatment guidelines that affect products of companies that supported them. There is presently no governmental regulation in Nigeria addressing this issue and the professional code of conduct is not specific with regards to gifting from industry to physicians.
The Medical and Dental Council of Nigeria (MDCN) is empowered by the Federal Government to regulate the professional conduct of physicians and is in a good position to help prevent or reduce the occurrence of these conflicts. These can be done by enforcing the following:
Prohibition of the traditional way in which pharmaceutical companies contact physicians through their sales representatives will be a good start. This will help to eliminate potential sources of unwarranted influences. These include all gifts, meals, payment for CME, and travel expenses to meetings. This will limit their contact and influence on physician decision-making. Free samples of pharmaceutical products to physicians should be banned since these provide an avenue for physicians to try these drugs on patients even when there are available cheaper unbranded products.
Other ways in which COI can be prevented include excluding physicians and all healthcare professionals with financial relationships with drug manufacturers from hospital and medical group formulary committees and committees overseeing purchases of medical devices. This will ensure that decision-making for formulary drugs and medical devices is based solely on the best available scientific evidence.
Drug companies are known to be responsible for sponsoring many CME programs. They usually have their products either along the corridors or have one of their paid researcher consultants deliver a talk in between lectures. This present method should be banned. Companies interested in contributing to medical education for medical students, residents, and consultant physicians should send their contribution to a central agency from which the funds will be disbursed to accredited CME providers. This arrangement would permit the ultimate recipients of funds to remain free from influence by any one donor company. Acknowledgment of the funds will be by the central agency. Since most companies evaluate their business ventures and support only to those who increasingly use their products, contribution of drug and device companies to CME sponsorship will reduce. However, the elimination of physician conflict from that more than compensates for the loss in sponsorship.
Sponsorship for attendance at professional conferences and meetings could also be sent by companies to a central agency like the MDCN who will send the same to the designated faculty and training program directors. This will ensure that trainees would no longer be directly dependent on a particular industry largesse for educational opportunities, thus reducing the conflicts that may arise in the use of their products for patients.
Physicians, especially those involved in training medical students, should not accept to function as paid marketers or spokespersons for medicine-related industries, so that the public’s trust on opinions of medical leaders will be upheld, without them thinking it depends on the highest payer. Publication of ghost-written articles of industry employees by faculty members should also be prohibited.
Research is expensive and so support from industries including pharmaceutical companies is welcome. However, to ensure independence, scientific integrity, and full transparency, the grants for general support should not be designated for use by specific individuals. In cases where the grant is specifically to research on a company’s product, the research contract should be such that there is no restriction on the dissemination of research results unfavorable to their product.
Transparency by physician disclosure to the patient has been suggested by many. 84% out of 906 patients in the waiting rooms of three general practices in 2007 felt that it was important for doctors to disclose any relevant competing interests. In addition, 79% wanted to know about any incentives obtained by the doctor. Furthermore, 78% believed that such disclosure would help patients make better informed treatment decisions and 80% stated they would have more confidence in their physicians’ decisions. They suggested that simple easy to read materials and verbal disclosures about COI that are directly relevant to their care. However, the truth is that disclosure does not eliminate the conflict. It only helps to sanitize the conscience of the physician. Most patients are not knowledgeable enough to understand what the physician is talking about. In addition, there is no way to confirm if the physician did disclose and what was the content of the disclosure. In fact, a criminal-minded physician can use disclosure to further convince an ignorant patient of why the particular product is the best. COI disclosure in the case of peer review of research article publication is different since the disclosure is to colleagues who understand the language of the discourse.
The above-suggested policies if adopted has many advantages since physician decision on which prescription to write or device to use will become more evidence-based, and practice guidelines of professional bodies become less subject to bias. Doctors will rely on more accurate information for decision-making with better patient outcome. There may also be increased use of generic products, as well as comparable but less-expensive patented products. In addition, the absence of industry representatives at hospital conference meetings and lunches and during CME lectures would increase the sensitivity among medical students and house staff to the values of medical professionalism and scientific integrity.
Ultimately, the implementation of these proposals will require that some physicians take a leading role and will best be fulfilled by those working in teaching hospitals. This is because they play a special role in educating the new crop of physicians and the importance of professional ethics in medical practice is best laid as a foundation in medical school. Teaching hospital faculty will be able to collaborate with MDCN officials to educate colleagues via personal interactions and CME lectures on the issues of conflicts arising as a result of the present arrangement between physician practice and pharmaceutical industries. Oversight functions will be needed to ensure compliance by all concerned. These policies will help the medical profession reaffirm very publicly its commitment to put the interests of patients first. All physicians whether working in general or teaching hospitals should be held to the same level of accountability. This is because unless it is an MDCN regulation, some hospitals may decide not to adopt these measures, thereby putting those who adopt them at a disadvantage in terms of paying for many needed financial services.
| Conclusion|| |
Physicians are susceptible to pharmaceutical industry and PSR interactions, which influences their clinical decision-making, leading to greater prescriptions of branded drugs over low-cost generic medicines and increasing healthcare costs. Therefore, there is a need to institute and implement stringent policies curtailing physician– pharmaceutical industry and PSR relationships, as well as put in place educational programs to increase awareness. Research grant contracts should be clear and uncompromising in stating the primary interest of maintaining research integrity by publishing only the truth.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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