International Public Health

[.green]Josh Gabert-Doyon:[.green] In response to the Covid-19 crisis the historian Mike Davis recently wrote that “capitalist globalization now appears biologically unsustainable in the absence of a truly international public health infrastructure. But such an infrastructure will never exist until peoples’ movements break the power of Big Pharma and for-profit healthcare.” What would you imagine to be a “truly international public health infrastructure”?  

[.green]Diarmaid McDonald:[.green] One of the most troubling things about Covid-19 has been the response – the nationalistic, competitive isolationist responses from governments. You've got people fighting over supplies of personal protective equipment and shipments of medicines being stopped from leaving countries.

Lots of the way that governments have chosen to respond to his has been diametrically opposed to what good pandemic response looks like, which is based on collaboration, openness, and coordination. It has certainly highlighted loads of flaws in the way that we've tried to organise global public health.

I think it's really alarming that we have the WHO forced to run a crowdfunder to cover its core costs and functioning. And that's going to be exacerbated by Trump's efforts to deflect attention away from his own failings to respond to the crisis effectively by cutting and suspending US funding to the WHO.

What would a truly global and more sustainable health infrastructure look like? It would be one that more accurately reflects and allocates resources to where public health need is greatest. I work closely on access to medicine issues in the pharmaceutical innovation model. And what we're seeing is that it's currently driven, under the capitalist model, by potential profit. We get innovation where companies can make money. That's how we drive the development of medicines we need as a society. The system we've designed to provide the really essential service of providing new medicines, treatments and vaccines, we have handed over to the market. Quite often what the market decides to be important and valuable and worth investment does not align with what global public health needs.

Historically we've had real critical underfunding of diseases that kill people every year. Because those people are poor and often black and brown, medical research for those diseases doesn't happen – there's not enough money to be made for it. And we're seeing increasingly that problem playing out for Western healthcare systems and patients in the West as well. We have a huge crisis of antibiotic resistance and we're not seeing the testing of new antibiotics because again, there isn't significant profit to be made there by the pharmaceutical industry.

With Covid-19. we haven't had the investment that's required to develop potential vaccines. Last year there were only 6 clinical trials in operation that were focused on Coronaviruses – Covid-19 is the third in the last two decades of Coronavirus outbreaks. We had potential candidate vaccines that had been brought to development with the use of public taxpayer funds, largely from the US government, but from others as well, and when it reached the development pipeline stage (which is normally where private sector investment comes in) that private sector investment didn't kick in. And researchers who have been involved in that side are saying that's simply because the private sector didn't want to spend money developing a product that was just going to sit on the shelves. We didn't get the private sector investment that could have brought those vaccines much closer to the point where they could have been brought for use during this global pandemic.

We have to transform that aspect of global health architecture so it's properly aligned with global public health needs and not one that is purely framed around the profits that companies can make with the monopoly we grant them on medicines.

Patenting

[.green]JGD:[.green] Can you tell me a bit more about how the system of patenting affects our response to pandemics?

[.green]DM:[.green] In the same way we saw with the very nationalistic responses, we're also weakened by the profit-driven incentives within the drug development process and the way we ensure access to the products of that innovation. The system assumes we will get private sector investment in areas where we need new innovation. And that didn't happen. We have this big mismatch where all the investment is coming from the public sector. Even when those vaccines did get developed and perhaps looked like they could have a promising impact on Covid-19, despite the public investment we have no guarantees that they will be accessible for everyone that needs them or affordable for health systems around the world.

We've paid a lot of money but we've got no conditions attached to the license agreements when we sign over the technologies to the private sector. We saw that the private sector's first response to Covid-19 was those companies that did have promising technologies sought to further strengthen their monopoly rights to those products.

For example, Gilead has got a treatment called Remdesivir that has the potential to be a useful treatment for Covid-19, and they sought additional monopoly protections through regulatory mechanisms in the US as soon as they realised there was scope for it to be used with Covid-19. They were forced to relinquish those monopoly rights after public outcry, but we see what their gut response is, which is to heighten barriers to access and make it more likely that it would be difficult for people to use those products unless it was through them and through the very tight monopoly that gives them complete control over price.

We also saw in the US the pharmaceutical industry was really effective with the huge Coronavirus bill that was put through Congress and which included billions of dollars for the response, including billions in subsidies for research in Covid-19. That included, in its draft form, some stipulations around accessibility and affordability but the pharmaceutical lobby effectively stripped those terms out of the bill. That's one of the most important and dangerous things that we've seen – the extensive control that the pharmaceutical industry has over our political process which is leading to policymaking that's going to make it more difficult for us to ensure we have an equitable response to the pandemic.

What we need to see and what should be happening is more of what we've seen with governments like Costa Rica, which is for the WHO to pool all of the intellectual property, both patents and other technical know-how, of all relevant Covid-19 technologies, tests, treatments and vaccines so that every country in the world could draw from that pool, which would allow multiple competing manufacturers to produce at the scale that's needed and at prices that are affordable. That kind of collaborative global effort is what we need as opposed to the individualistic and profit-oriented responses we've largely seen from the pharmaceutical industry.

[.green]JGD:[.green] What else would you want to see in terms of changes to how research and development (R&D) work? How else could R&D incentivise innovation in medicines and pharmaceuticals?

[.green]DM:[.green] We have one model right now which is heavily subsidised by taxpayers. Every new molecular-based entity that was approved from 2010-2016 in the US had support from the National Institute of Health, which is a US federal government body. The existing system already heavily relies on public investment. But we still have got this belief that the best way to steer private sector involvement in this process is giving them the promise of monopolies where they can charge as much as they like to recoup the costs and pay for future R&D funding. That leads to a whole raft of problems. I've already mentioned that it ends up steering research towards where money is going to be made instead of where it would have greater public health impact. It also leads to the problems that we've seen with the lack of guarantees around access and affordability, which gives rise to the huge problems we have around high drug prices right now.

It also causes a lot of other problems, like a failure for there to be good, open collaboration across research to ensure that we're not duplicating work and being efficient as we possibly can be in structuring our investments.  

We can change that system to one where other incentive are in place, rather than the promise of monopolies. For example prize funds which would say: "we're going to pay out £3 billion to the first company that comes up with an effective vaccine for Covid-19." There are lots of ways those prizes can be structured but it allows us to align our incentives with public health need. That means we can still have the effort of independent research organisations and private drug and biotech companies, but it means that it would be steered in a way that would have greatest public health impact. And it also means that since they've been rewarded through that prize fund we don't have to reward them with a monopoly, so we'd be able to have multiple manufacturers producing the end product, and that competition will drive down price and allow us to recoup the price that we paid upfront for innovation, through much lower drug bills.

We can also just do straight-up grants. We can do grant-funding much more efficiently so that we're funding researchers to do the innovation that we actually need. That's another very functionally effective way of investing in research and development.  

And lastly, I would say there's a strong case for us to have a much more integrated, democratically-controlled public sector ownership of the whole drug-to-development pipeline, right from the early stage of research which is dominated by public funding right now, straight through to the later phase with the funding of clinical trials in humans, which is currently mostly done by the private sector. We could have a fully integrated public system, right through to public manufacturing of medicines so we could overcome not just the high prices but the production challenges we're seeing play-out with the over-reliance on a marketised, outsourced, privatised supply chain, which is also leading to some issues around supply that we’re currently seeing.

‍Recent History

[.green]JGD:[.green] What does the recent history of outbreaks like SARS, Ebola, and H1N1 tell us about how our system responds to these crises?

[.green]DM:[.green] I think it's really tragic that we've had multiple outbreaks. I think Ebola is the most damning. What happens generally is that when the outbreak starts to threaten Western interests – when white people start to be affected by these conditions – that’s when there’s a response. Ebola has been killing people with very little attention or care from the West in Central Africa for decades, and it was only when the West African outbreak played out and started to threaten people in Europe and America that we started to see interest in investing in the development of a treatment or a vaccine. What we see then is a spike of interest and a flurry of investment. But once the pandemic passes the profit motive also passes, so there is not the same residual justification in companies to invest in treatments of that pandemic.  

This is the third Coronavirus in the last two decades to threaten global health. Following the SARS outbreak in 2002, there was an investment in the development of potential vaccines. Some of those got to the later stages and were looking for that private sector investment which usually covers clinical trials and that investment wasn't forthcoming. We could have built upon those previous epidemics to make us better prepared for the one we're living through right now but we didn't do it largely because of the intrinsic link between the motivation and resources to invest in R&D and the profits they make from them.

Accessiblility

[.green]JGD:[.green] A lot of people hearing about the Covid-19 vaccine being prohibitively costly would say "won't the state just cover this to make sure the vaccine gets to everyone?" What would be your response to that? What are the stakes here, in terms of health inequality and what that actually means when a vaccine isn't universally accessible?  

[.green]DM:[.green] It remains to be seen, but what's interesting is that the pharmaceutical industry is very much aware that what's playing out right now exposes the dysfunctionality of the current model. So we have seen on their part efforts to head off more far-reaching reforms of the current pharmaceutical innovation system by making promises around affordability or taking steps to collaborate and open their research libraries, which under other circumstances they wouldn't be doing. It's great that they're doing that but we need to question whether that is a realisation on their part that there is a heightened level of risk right now. With such fundamental changes happening across so much of our economy right now, this might be the time when decision-makers and politicians decide to fix this problem in a holistic way rather than a piecemeal way that gets us through the next six months. There is every chance that these technologies will be affordable and will not over-burden health care systems, and that may be the case for the West but that remains to be seen, But there is every chance that they will not be affordable for the rest of the world.

What we see with this virus, one of its particular traits is it's high-level of transmissibility. It's a very infectious virus. What it shows is really is that until this virus is defeated everywhere it's defeated nowhere. Even if we're acting out of pure self-interest, we need to make sure that we're adequately funding health responses of governments all around the world, and that we're ensuring that the prices of these technologies are affordable in every socio-economic context. That is both tackling the inequalities within countries and those that play out on a global level.  

One thing as well is that the virus is laying bare some of the more fundamental failings in not just the structure of the innovation model but the prioritisation given by governments around the world to health. The UK is being more badly affected because of the under-funding of the NHS and adult social care over the last decade. If we are going to respond to Coronavirus on a global level we're going to need a global investment in health infrastructure, driven by a public sector model that provides universal access free at the point of use for all citizens. That will require looking at countries across Africa, Asia, Latin America and former Soviet States in Eastern Europe and Central Asia to build a sustainable health system in all of those country contexts so that they're able to effectively undertake the health responses that will bring Covid-19 under control, but also malaria which is killing many more people this year, in all likelihood, than Covid-19 will. To properly respond to that and properly enable everyone who needs access to HIV treatment can get access to it, tuberculous, and other neglected tropical diseases as well.