'Help prevent a sequel': a pre-COVID cautionary tale

🌎 TRIPS down memory lane, with a film.

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"Help prevent a sequel." 

This was the last line that showed up on the screen in the closing sequence of Fire in the Blood—a film that documents how activists battled against pharmaceutical companies to turn the tide against a system that kept the supply of AIDS drugs out of the reach of poor countries and contributed to millions of deaths, mainly in Sub-Saharan Africa.  

I watched it a few years ago at one of the first festivals organised by Global Health Film (you can still catch it on Netflix). The film was powerful then, and it has renewed relevance now.

We’re starting to see more impassioned calls for an end to “vaccine apartheid” as limitations in global sharing, production and distribution of COVID vaccines become more apparent, and traced back to how the system of pharmaceutical production is set up.

In this week’s WorldWise briefing, I remarked that efforts to temporarily waive the patents that keep vaccines from being produced by more than a handful of companies face an uphill battle.

This piece by journalist Aisling Irwin in Nature explains what that effort looks like on the international stage. She writes:

India and South Africa are among the countries involved in a campaign to get COVID-19-related intellectual-property rights temporarily waived. This, the campaign's proponents argue, will unleash a cascade of production.

Last October, the two countries asked the World Trade Organisation (WTO) for certain intellectual-property rights on COVID-19 medical tools and technologies to be suspended until herd immunity has been reached. The proposal has been gathering support, and is now backed by around 100 countries, and by a diverse coalition of organisations.

In that article and in others, proponents of waiving COVID vaccine intellectual property rights (IPR) often cite the painful history of making AIDS drugs accessible to poorer parts of the world hit hard by the disease. The story of how a generic version of antiretroviral treatment (ART) eventually came to be put on the market—and finally become affordable—involves legal ins and outs that Fire in the Blood manages to transform into a compelling watch.

A parenthesis: 

The bottom line in all this has to do with legally convoluted international agreements and patent regulations. If that sounds like a turn-off but you’re curious to know how it relates to the pandemic, head to a succinct summary of how IPRs block COVID vaccine access in this article for the BMJ by Salla Sariola of the University of Helsinki, who argues global health scholars need to support vaccine access campaigns. 

At the heart of the system is the international agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), whose rules prevent developing countries from making low-cost versions of drugs. Though now thrust into the spotlight, arguments to change TRIPS rules, and analyses documenting how its rules favour the corporate sector in the developed world, have been around for at least two decades

To say this conversation is not new is an understatement. But the urgency of it is new.

Back to how it matters for COVID:

This article by Ken Shadlen, a professor of Development studies at LSE in London, which was published in June—ahead of the game—also looks back at antiretroviral drug patents to analyse their implications for this pandemic. This is how he describes the turning point of the AIDS story:

While many factors contributed, one thing, ultimately, brought prices down and enabled the massive expansion of AIDS treatment: competition—specifically, competition in the form of antiretrovirals from India. Not only were Indian drugs affordable, but their presence led originator firms to lower the price of theirs too.

At this point, readers may be asking: if TRIPS requires countries to grant patents on pharmaceutical products, then how is it possible that Indian firms were able to supply these drugs? The simple answer is that AIDS treatment expanded on the basis of older drugs that pre-dated TRIPS and therefore never obtained patents in India.

Shadlen goes on to point out that this loophole doesn’t hold in the case of Covid-19: there are no patents that pre-date TRIPS.

So where does that leave us?

It’s not clear. Shadlen and Sariola cite the option of “compulsory licensing”, a TRIPS loophole allowing the third-party manufacture of a patented drug, which both conclude—for different reasons—just won’t cut it in this case. Some of the reasons they give seem to tally with arguments cited in Irwin’s report; for example, that a temporary exemption won’t solve the problem because vaccines are much more complicated to produce. Irwin’s report proposes that technology transfer through licensing rights could be the best bet to speed up the local manufacturing process. According to Shadlen’s analysis, low local manufacturing capacity would be a limitation. He suggests that a breakthrough could come from a least developed country producing its own vaccine without patenting, but concludes the chances that this can plug the global access gap are slim.

You get the picture—there are no easy answers here. Gone are the days when Jonas Salk simply opted against a patent for his newly developed polio vaccine. The decisions made in the response to this pandemic involve more than public-health considerations, and that’s been clear for some time.

This takes me back to watching Fire in the Blood, and the reflections it elicited—which seemed a bit abstract at the time—about the social-political context to health science:

Research, development and technology to develop new medicines are not enough to meet social needs equitably: health programmes also need to consider the mechanisms—logistical and political—that will deliver those innovations to those who need them, as well as make them economically viable.

Many health researchers will shift uncomfortably in their seats at the idea of engaging with these issues. They touch a politicised space that, more often than not, is outside the comfort zone of natural science—understandably so, considering core values such as objectivity and empiricism.

It’s safe to say that on this, things have changed.

But the last sequence of the COVID vaccines access story still remains to be seen.

A final note from the week’s soundtrack 🌎

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