Ten months in, there are more than 8 million confirmed cases of Covid-19 in the U.S. and over 40 million cases worldwide, adding new urgency to the search for a vaccine. But as the pandemic continues to rage unabated, structural weaknesses in how we research, develop, and distribute medicines have come into sharp relief, raising questions about who will be able to access an eventual vaccine. Priti Krishtel, co-founder of I-MAK, sat down with Ashoka to discuss myths and reality in America’s quest for immunity.
Ashoka: What can we expect when a vaccine finally goes to market?
Priti Krishtel: The reality is that a vaccine is no silver bullet. Some people are going to get it first and some people aren’t going to get it at all. We’ve seen that play out with personal protective equipment, with ventilators, with testing. Professional basketball players were getting routinely tested before the rest of us could access a single test.
We need to shift away from the idea that vaccines are a quick fix. The problem we’re facing isn’t finding a vaccine for Covid. It’s building a system that allows us to respond effectively not just to this pandemic, but to the next one and the next one. If we address the drivers of lack of access — things like high drug prices and inequities in the medicines system — then we can ensure that treatments for cancer, diabetes, and a whole host of other diseases are accessible to people who need them.
Ashoka: American taxpayers have invested over $12 billion of public funding for vaccine development. Why doesn’t that guarantee access?
Krishtel: In my mind, public funding of vaccine research creates a social contract. If taxpayers subsidize all or a substantial part of the research for a vaccine, then it should be broadly accessible. You can’t just use that publicly funded knowledge to fill your coffers. The problem is, we see the government deploying huge amounts of cash to fund vaccine development without any commitments around access and affordability. There’s not a venture capitalist alive who would do that.
Take, for example, the company Moderna. It has promised not to enforce patents on its vaccine during the pandemic, but it’s not clear what that actually means for access. For example, it appears that Moderna will not share its technology to accelerate scale-up. The company has also said that it won’t enforce its patents during the pandemic period — but will Moderna be the one determining when the pandemic is over? It’s crazy to me that we continue to rely on the benevolence of individual drugmakers to ensure people have access to life-saving medicines.
Ashoka: In a pandemic, we’re only as safe as the people around us. Yet we are seeing rising “vaccine nationalism.” What are the implications of that?
Krishtel: We’re being told that there’s only so much vaccine to go around and that supplies will need to be rationed. But that scarcity is a choice. It’s a result of a system that incentivizes drugmakers to lock up knowledge instead of sharing it and mobilizing the full weight of our global manufacturing capacity. It’s like sending one life boat to rescue an entire cruise ship.
To make matters worse, we’re seeing countries signing private agreements with drugmakers to get as much for themselves as possible. It is really disappointing to see that so many of the steps we’ve taken over the last few decades to build partnerships and encourage global cooperation are being eroded right now. The result is that poor countries will be at the mercy of rich ones and unlikely to get the vaccine for years. That’s not only morally horrifying, but it’s also bad public health. A recent study found that we could cut the number of Covid deaths in half if we took a more collaborative approach.
Ashoka: Even before Covid-19, America was facing an unprecedented drug pricing crisis. What is driving it?
Krishtel: Our focus for the last two decades has been on the patent system because patents are a root source of the pharmaceutical industry’s power to set prices. In theory, a patent expires after 20 years. After that, other drugmakers can enter the market and competition brings prices down. But companies now regularly file dozens or even hundreds of patents on a single drug to extend their monopolies for as long as possible.
In 2018, we investigated the 12 best selling drugs in America. We found that, on average, there were 125 patent applications being filed per drug and many of them were granted. Drugmakers were able to extend their monopoly from 20 to nearly 40 years, during which time they could set prices at whim.
We’re in an urgent drug pricing crisis. Millions of Americans can’t afford medicines and it is taking a toll on their physical and financial wellbeing. If we’re serious about lowering drug costs, we need to close the loopholes that give drugmakers total control over prices for far too long.
Ashoka: What needs to be done to address this problem?
Krishtel: We have a framework to start reimagining the system so that patents don’t pose an unreasonable barrier to access. At a high level, it includes raising the bar for what gets patented, increasing oversight of the patent office, and creating avenues for public participation.
More broadly, we’re working with our partners to make this a catalytic moment for reform. In global health, change happens when distinct social forces intersect at key moments. In the late 1990s, HIV medicines were unaffordable for people in the hardest hit countries of the Global South. There was a wave of public outrage and drug companies eventually lowered prices for the lowest-income countries. It led to the most large-scale expansion of treatment access the world has ever seen. I believe we’re at a moment like that again. Our drug pricing crisis is colliding with a global pandemic and a racial reckoning, and there is an incredible window of opportunity for change.
Ashoka: Say more about the racial reckoning. How does that connect to Covid-19 and access to medicines more broadly?
Krishtel: The racial reckoning is forcing us to examine all of our systems, including the medicines system, through the lens of racial justice. It’s no accident that Black and Brown people have been disproportionately affected by Covid-19. Racism is institutionalized at every step of the medicines pipeline, from where research dollars are allocated to who gets access to treatment. For example, diseases that primarily affect people of color are chronically underfunded. When drugs are developed, Black and Brown people are often less likely than other groups to be able to access them. Ultimately, what we end up with is a hierarchy of health, in which our ability to heal depends on where we happen to fall on the economic ladder. There is a distinctly racialized dimension to who gets hurt most in a system like that. Tackling these injustices is a key part of I-MAK’s vision for reform.
Ashoka: Recently, several pharmaceutical CEOs were called before the U.S. Congress to testify about their pricing and patenting practices. What were the key takeaways?
Krishtel: We have been working for three years to draw attention to the drug patent problem and we’re thrilled that legislators are starting to pay attention to the issue, in part because of the evidence I-MAK has been able to provide. At the hearings last month, we saw legislators from both sides of the aisle acknowledge that innovation without access is meaningless, which is a huge shift from the “innovation for its own sake” rhetoric we have seen in the past. So, that was an encouraging sign coming out of the hearings.
But I’d like to see more recognition from Congress that this is not just about individual bad actors. While I’m glad pharmaceutical executives are being called to account, the reason they engage in harmful corporate practices is because that’s what they are incentivized to do. My hope is that people don’t walk away from the hearings thinking this is about a handful of CEOs. The root causes of our broken medicines system have to do with skewed incentives, lack of oversight, entrenched racism, and a whole host of other thorny systemic problems. We need to get working on those issues if we want to get out of this mess.
Ashoka: What’s ahead for I-MAK?
Krishtel: Over the next few years, we’re going to be developing a comprehensive blueprint for patent reform. But what I’m most excited about is the process we’re using to do it, which we call “participatory changemaking.” It’s basically bringing a bunch of people together who see the patent system from different vantage points. There’s not nearly enough dialogue between, for example, patent examiners and patients affected by patent decisions.
For reform to succeed, we need to build much needed connection and understanding between ideologically, sectorally, and geographically diverse stakeholders, and foster a less polarized, more productive discourse around reform. In this moment, that feels more necessary than ever.