‘We’re not dealing with bad apples. We’re dealing with a rotten tree.’

I am a fan of Trevor Noah and especially over the last year for his observations about race and policing in the United States. A recent monologue from the Daily Show host about the American system of policing resonated because it is how I often think about our current pharmaceutical system, and its consequences during this pandemic. Starting at 3:33, Noah remarks (which I have edited a bit for brevity):

The system is more powerful than any individual. The system in policing is doing exactly what it is meant to do in America — and that is to keep poor people in their place — who happens to be the most poor in America — black people….It’s a system. It’s not broken, it’s working the way it’s designed to work. And once you realise that….you realise..oh…we are not dealing with bad apples, we are dealing with a rotten tree — that happens to grow good apples. But for the most part, the tree that was planted, is bearing the fruit that it was intended to.

This weekend marks one billion doses of COVID-19 vaccines administered globally. If we assume that there had been ‘absolute fairness’ in vaccine allocation (e.g. vaccines were shipped to each country according to its population size) — every country would have vaccinated a bit more than five percent of its population — enough to vaccinate all healthcare workers, as well as those at the highest risk of severe morbidity or mortality. Of course, things have not worked out that way — wealthy countries account for 16 percent of the world’s population but have acquired more than half of all vaccine doses. As of mid-April, rich countries have administered 87 percent of all doses, while low-income countries have administered just 0.2 percent of all COVID-19 vaccines.

Things have worked out exactly as the current pharmaceutical system was engineered — it is — to quote Trevor Noah — ‘working the way it’s designed to work’.

For those countries on the wrong side of the vaccine divide today, there is a grim familiarity — this is not a new story but one that gets retold with a different cast of characters (and products). Previous versions of this story may not have been about such naked competition for supply — that is unique to the COVID-19 pandemic — but the story of our pharmaceutical system is one that is designed to promote and exacerbate exclusion, injustice, and immoral behaviour, which ultimately results in — to use polite, sterile public health terminology — ‘avoidable morbidity and mortality’.

Over the last few decades, we (access advocates) have spent our careers calling for measures to overcome one ‘market failure’ before moving on to the next one. It is because of those experiences, and the bitter lessons of each access fight, that advocates warned last year that without drastic measures, there would eventually be gross inequity in access to vaccines (and medicines and tests).

At the somewhat hopeful launch of the ACT Accelerator in April 2020 (the ACT Accelerator is an entity that convenes several global health agencies and foundations to ‘accelerate’ innovation and access to medical technologies), you wanted to believe the words of global leaders who backed and financed the Accelerator while also delivering soaring rhetoric of ‘equitable access for all’. But if you had been involved in pharmaceutical issues for any period of time, you could also imagine these same politicians delivering their message of solidarity and goodwill, and immediately afterwards placing an advance order for vaccines and drugs in development. In the end, not only did the plans to ensure equitable access ignore the lessons of past failures (and successes) of the pharmaceutical system — it allowed the very same high-income country governments and drug companies that have been responsible for the repeated failures of the last thirty years to be in control of the COVID response.

So what is our pharmaceutical system designed to do?

First, the pharmaceutical system is designed to convert public resources into private benefit, with nothing going back to the public except a product. Governments have been responsible for developing, funding, and testing many of the critical technologies that underpin the COVID-19 vaccines, and have also spent well north of 90 billion Euros on paying for the development and manufacture of medicines, vaccines, and tests over the last year. Yet these same governments have not secured any ‘public benefit’ in negotiations with drug companies. No transparency — of pricing, of R&D costs, of cost of manufacturing. No sharing of intellectual property or know-how. High prices for the vaccines despite the massive public subsidy. And no workable mechanism to allow governments to take back control if things are not going well (for example, right now).

Second, the pharmaceutical system is designed to work effectively for the wealthiest and most powerful countries and people, and sub-optimally or not at all for the rest of the world. For COVID-19, this is in part because high-income countries, who put up most of the funding for technology development, chose to corner supply instead of making demands that would promote the public good (see above). Again, the fact that high-income countries could simply ensure that the system benefits themselves is exactly how the system is designed to work. What is unique about COVID-19 is that since every country needs access to the same technology at the same time, the benefit that the wealthiest countries pursued was first in line access to vaccines, drugs, and tests.

Historically, as during COVID-19, high-income countries pay for most of the research and development (and comprise a substantial percentage of the pharmaceutical market because they overpay for medicines and vaccines). Since high-income countries both subsidize R&D and overpay for drugs that are approved, companies are encouraged to only focus their resources on developing medicines and vaccines that are of the highest priority to the wealthiest countries while ignoring the unmet needs of low- and middle-income countries (this is also due in part to the priority setting of high-income countries that finance or fund early stage research and drug discovery, although public sector investment into so-called neglected diseases has improved over the last two decades).

The upshot is that for those diseases that affect neglected populations, there is inadequate investment (in the parlance of the drug industry, investment in these priorities is an ‘opportunity cost’), and thus for people who suffer from such diseases, they must wait at the back of the line for investments in R&D to meet their needs. In other words, the pharmaceutical system has always rationed ‘access’ to the poorest — be it a lack of new medicines or vaccines to prevent or treat neglected diseases, or in the case of COVID-19, little or no supply of COVID-19 vaccines.

When there has been a groundswell of support to reform the pharmaceutical system in high-income countries, it is mostly focused on ensuring that the prices high-income countries pay are reasonable, instead of reforms that promote equity for all populations, and especially those needs that are ignored or marginalised in the current pharmaceutical system. For example, the major drug industry reform legislation tabled in the U.S. Congress this year is focused almost exclusively on lowering drug prices on behalf of Americans. Similar discussions are underway in Europe.

Third, the pharmaceutical system is designed to deliver outsized profits to pharmaceutical companies. That’s obvious, but again, the point here is to say that the system is working exactly as it was designed. Drug companies that have managed to obtain emergency approval for their vaccines are enjoying bumper profits. Pfizer is projecting between 15 and 30 billion dollars in revenue from its COVID franchise this year, and significant profits in the coming years if it is able to increase the price of its COVID vaccine boosters (that will be required for successive variants). Moderna is likely to emerge from the pandemic as one of the world’s largest drug companies, much as Gilead Sciences vaulted into the ‘big leagues’ from the AIDS pandemic.

Fourth, once the pharmaceutical system breaks down, there is a scramble to put in place charitable and voluntary measures to mitigate the worst consequences. With the pandemic out of control in India and Brazil, and perhaps eventually in other countries that have managed to control the pandemic until now, we will now see a hurried raft of voluntary, humanitarian, and philanthropic measures to put a band-aid on an emerging catastrophe. These voluntary initiatives are of course too late to forestall the heavy loss of human life.

This story is not new. The AIDS pandemic was supposed to have been a ‘never again’ moment — resulting in a transformation of the pharmaceutical industry — as demands for appropriate R&D, affordable prices, and limits on intellectual property had put the industry on the defensive two decades ago. Yet for all the claims that the AIDS pandemic led to a seismic change in the pharmaceutical industry (and global trade rules), the last decade has been noticeably calmer and tamer.

We have settled instead, with the launch of each new antiretroviral medicine (or medicine to treat a co-infection, such as Hepatitis C), into a predictable dance of charitable measures — such as voluntary licensing and not for profit paediatric research programs — that can ensure that many people living with HIV have adequate and timely access to affordable and effective antiretroviral therapy. Many would argue this has been tremendously beneficial to people with HIV and AIDS and has codified certain expectations of how pharmaceutical companies address the AIDS pandemic. I agree. But because the AIDS pandemic did not force a fundamental rethink of the current pharmaceutical system, we were always setting ourselves up for the next global catastrophe when the ‘polite rules’ that have been established are thrown out the window.

And so now, with a catastrophe upon us, we are inventing a new ‘charitable equilibrium’ — whether it is the COVAX initiative’s intention of only vaccinating 20 percent of all low-income countries in 2021, or the donations by a few high-income countries, such as France, to reach the most at risk and vulnerable populations this year. More hopeful and transformative measures, such as decentralised production of mRNA vaccines or a WTO waiver of IP for COVID-19 technologies, may still succeed, but even if they do, the restrictions on its wider applicability are likely to be significant, and the rest of the pharmaceutical system will lurch along until the next global catastrophe.

We were never going to have a fair and just global immunisation campaign to address the pandemic. We entered into the pandemic with a broken pharmaceutical system that: allows corporations to take control of public assets and resources with no accountability, provides most of the benefits of the pharmaceutical system (R&D outputs or supply) to a narrow set of high-income countries, assures drug industry profitability during the worst of times, and that falls back on voluntary measures and charity once the death and suffering is too difficult to avoid.

For those of us who are access advocates — call us ‘storm chasers’ or ‘disaster junkies’ — we move from one access tragedy to the next — knowing how it will unfold and how it will be resolved — even as the same underlying flaws in the pharmaceutical system remain. Real change is not possible unless there is collective anger, and collective demand for reform.

For people who are on the wrong side of the vaccine divide, there is anger. Right now it may be anger driven by dissonance — of the left-behind looking at images of twenty year olds getting vaccinated in the United States, of Facebook posts of champagne brunches, even as they worry about a sister who is a nurse, a friend who is an asthmatic, or a parent who is pushing 80. I can only hope this anger deepens and expands, and is not just focused on the disaster that is unfolding, but why it is happening, and what can be done to uproot the rotten tree and replace it with something better.