Corporate Power and Access to Healthcare

Pyrimethamine, more commonly known as Daraprim, is a drug that is frequently prescribed for the treatment of protozoal infections and malaria around the world. It is also very often prescribed for HIV positive patients in combination with other drugs. Until recently, not many knew of this drug even though it features on the World Health Organization’s List of Essential Medicines. However, that changed overnight as a new pharmaceutical company acquired Daraprim and raised its price to a whopping $750 for a pill. This development also brought attention to the rising prices of other prescription drugs, uncovering a trend which is seeing the interests of patients being pitted against the profits made by pharmaceutical and insurance companies. We know from our readings of Smedley and Smedley and Kris Holloway’s account of her experiences in Mali, that race (beyond its relation to socio-economic status) and gender are major determinants of access to healthcare around the world, but socio-economic status which is influenced by both of the aforementioned factors still remains the primary determinant. If you live in a country like the UK, where the state bears most of the healthcare costs, the inflation of pharmaceutical prices may not affect you much; however, for most of the developing world, where 70% of the world’s population resides, the price of medicines can be a barrier to being able to avail treatment for a disease.

 

90% of the people living in developing countries have to buy their own medicine. Diseases like malaria and HIV for which Daraprim is prescribed are more prevalent in developing countries. But how is an ordinary citizen from sub-Saharan Africa, where the average annual income is less than $750, supposed to afford sustained treatment for a long term disease like HIV if a single pill costs $750? This problem is not limited to HIV and malaria either. A recent study found that treatment for pneumonia in Tanzania costs an ordinary worker a whole month’s wages.

 

Some countries like India are able to subsidize some medication but most developing countries don’t have the capacity to do that. The majority of medication in most of these nations has to be imported from overseas as only 7% of world’s pharmaceuticals are produced in the developing world. Multinational pharma corporations have entrenched themselves on the global health landscape. Given that their global presence has prevented the development of domestic pharmaceutical industries, their manipulation of prices is a major concern as a lot of people depend on them for their medicines and this gives these corporations immense power. Power that they can wield in a socially responsible manner or use to milk people for their money.

 

Multinational corporations extol the virtues of corporate responsibility. Nevertheless, their track records show that they tend to exploit people and resources (their motivation for going multinational), pollute the environment and disappear once they’ve gotten what they wanted. As we learnt from our readings about the tobacco industry, profit driven corporations stop at nothing to raise their profit margins, even if that means selling addictive and harmful products like cigarettes to children or promoting a culture of smoking. If tobacco companies which sell a health hazard are able to have their way, one can’t help but wonder what pharmaceutical companies on whom the world depends on can get away with.

 

At the end of the day, the pharmaceutical sector is a business. Like many other corporations, they may not be conscientious and may even be willing to deny the poverty stricken and the impoverished their pills and let them suffer to be able to rake in more profits. This makes me wonder, are these corporations any different from the colonizers of old who used political power to exploit others economically? After all, the East India Company, the so called original corporate raiders, started out as a trade mission and evolved into a power hungry, exploitative machinery. Capitalist tendencies of pharmaceutical companies as illustrated in the instance of Turing Pharmaceuticals and Daraprim are a warning sign. In fact, journalistic organizations like WikiLeaks have being tolling the alarm bells for a while. WikiLeaks’ latest exposé, that of the Healthcare Annex to the secret draft “Transparency” Chapter of the Trans-Pacific Partnership Agreement (TPP), outlines the construction and enforcement of a transnational legal system that will allow multinational pharmaceutical corporations to exploit the world’s basic human need for healthcare by strengthening their oligopoly. While the sources may be questionable, the concern being aired is quite real… For long, public health scholars have highlighted the need for more healthcare professionals like doctors and nurses in order to improve access to healthcare globally; however, if multinational pharma companies maintain their current trajectory, we may see the need for affordable medication added to that list.

WikiLeaks-TPP-Healthcare-Cartoon

 

Discussion questions –

How can states induce pharmaceutical companies to recognize their social responsibility and provide more equitable access to drugs? How might international organizations such as the World Health Organization play a role in this?

Over-priced medicines are certainly a big problem. However, underpriced medicines can be as well. In India for instance where the government subsidizes antibiotics, a combination of over prescription and self medication have led to alarming levels of antibiotic resistance. How can we allow people the access to medication and prevent them from misusing it? How can any pertinent regulations be enforced?

 

Holloway, Kris. Monique and the Mango Rains: Two Years with a Midwife in Mali. Long Grove, Ill: Waveland Press, 2006.

Boseley, Sarah. “Dying for Profit.” The Guardian, September 8, 2003, sec. Environment. http://www.theguardian.com/environment/2003/sep/08/wto.fairtrade7.

Brandt, Allan. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America. 1 Reprint edition. Basic Books, 2009.

Brink, Susan. “Why India Is A Hotbed Of Antibiotic Resistance And Sweden Is Not.” NPR.org. http://www.npr.org/sections/goatsandsoda/2015/09/17/441146398/why-india-is-a-hotbed-of-antibiotic-resistance-and-sweden-is-not.

Comaroff, Jean. 1997. “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body.” In Knowledge, Power and Practice, S. Lindenbaum, and M. Lock. University of California press, 305-29.

Cox, Joseph. “Surprise! Big Pharma Don’t Want Developing Countries Having Access to Cheap Medicine | VICE | United Kingdom.” VICE. http://www.vice.com/en_uk/read/american-lobbyists-are-fighting-to-halt-the-availability-of-affordable-medicine-to-the-3rd-world.

Dalrymple, William. “The East India Company: The Original Corporate Raiders.” The Guardian, March 4, 2015, sec. World news. http://www.theguardian.com/world/2015/mar/04/east-india-company-original-corporate-raiders.

Dorling, Philip. “Medicines to Cost More and Healthcare Will Suffer, according to Wikileaks Documents.” The Sydney Morning Herald. http://www.smh.com.au/national/medicines-to-cost-more-and-healthcare-will-suffer-according-to-wikileaks-documents-20150610-ghkxp0.html.

Kelly, Stephanie. “Testing Drugs on the Developing World.” The Atlantic, February 27, 2013. http://www.theatlantic.com/health/archive/2013/02/testing-drugs-on-the-developing-world/273329/.

McGee, Suzanne. “Daraprim ‘Profiteering’ Controversy Lifts Lid on Soaring Cost of Prescription Drugs.” The Guardian, September 27, 2015, sec. US news. http://www.theguardian.com/us-news/us-money-blog/2015/sep/27/daraprim-profiteering-cost-prescription-drugs-martin-shkreli.

“Medicinal Drugs in the Third World.” Text. Cultural Survival. http://www.culturalsurvival.org/publications/cultural-survival-quarterly/brazil/medicinal-drugs-third-world.

Pollack, Andrew. “Drug Goes From $13.50 a Tablet to $750, Overnight.” The New York Times, September 20, 2015. http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html.

Smedley A. and Smedley, B. 2005. Race as Biology is Fiction, Racism as a Social Problem is Real: Anthropological and Historical Perspectives on the Social Construction of Race. American Psychologist 60(1): 16-26.

Turnbull, Nancy. “Turnbull: On Inequality In Medical Spending And The Cost Hearings.” Commonhealth, June 26, 2011. http://commonhealth.wbur.org/2011/06/inequality-medical-spending.

30 thoughts on “Corporate Power and Access to Healthcare”

  1. It’s pretty clear that drug companies are the biggest “players” in this issue and that the healthcare system can relieve some of the burden for certain countries. However, providing healthcare/insurance/making medicine more affordable doesn’t appear to be enough. I want to bring to your attention that while the UK does relieve a lot of individual burden when it comes to healthcare costs, population health is not improved all that much by this. So while the UK may be better as far as expenditures look, it ranks 10th (to the USA’s 11th) when it comes to the number of healthy lives (http://blogs-images.forbes.com/danmunro/files/2014/06/TCFchart.png) Is better healthcare an important step to take? Yes. But there’s more that needs our attention than just cost and the UK is a testament to this. There are broader determinants of health than just health-care to keep in mind (and we have discussed these determinants and factors in class in more detail), like socio-economic status, gender, race, and environment.

    As far as solutions–the best answer to both of your questions (inducing companies to recognize their responsibility, lowering misuse) is communication, transparency, and awareness among the consumers themselves and among those administering and providing them. I’m unsure as to whether it would be more effective to impose a change externally or to try to influence individuals and let the change come from within. How well do these education efforts actually work? How much do medical workers know vs how much do they ignore for the sake of prescribing something cheaper/quicker? What I do think (feel free to critique this), is that eliminating benefits of prescribing certain medications (eradicating “deals” between doctors and governments and pharmaceutical companies or maybe replacing them with better ones??) is challenging but really important, that international law can step in but likely won’t be enough, and that the media/the public press/public opinion holds the most sway over these companies at present and can influence the people in power. In short, I think making a big fuss is efficient and has the capacity to be effective.

    1. Thanks for your insightful comments Sylvie! I certainly agree that there are broader determinants of health than just healthcare and a lot of these are interconnected. I tried to acknowledge the same in my post and since my focus was specifically on the access to healthcare, I attempted to highlight that socio-economic status is often the first hurdle in an individual’s ability to access healthcare.

      As for the UK example, I was trying to underscore the fact that most developed countries have full or partial, publicly funded healthcare (the US is not amongst them) and that these systems ease the financial pressures that people may face when trying to access healthcare (perhaps this is a naive understanding on my part). I do agree with you that none of these systems are even close to the ideal but I think a greater ratio of people in developed countries have access to healthcare in comparison to say a sub-Saharan country; the broader idea being that since corporations play such an important role in determining access, their actions (raising prices) will affect the developing world disproportionately.

      You bring up a great point about the ‘deals’ between doctors and pharma companies. Greater transparency will certainly go some ways into rectifying that problem. You’re also correct in observing that the public opinion as shaped by the media is an important factor in keeping corporations in check. In fact, since the media outcry on Turing Pharmaceuticals’ decision, the company has issued several media statement in order to recede from their position.

  2. Hello Harsh,

    I, too, was shocked to hear about the 5000% overnight increase in price from $13.60 to $750 per tablet of Daraprim. Yes, this is due to corporate power and their ability to take advantage of the power they have as the legal owner of the drug. But behind the pharmaceutical that owns this drug is the US Food and Drug Administration, which has laws barring the import of the same Daraprim (Pyrimethamine) from other countries such as India and parts of Europe, where the drug is sold at much cheaper prices (some even lower than the original $13.60 per tablet). The FDA also prevents other pharmaceutical companies from producing the same drug and selling it without hiring lawyers and researchers to produce the drug, a costly process that discourages companies from making their own, generic version of the drug. It’s easy to point fingers to the pharmaceutical company that raised the price in the first place, but there’s actually much more to it in that FDA regulations prevent other companies (both domestic and foreign) from competing with Turing Pharmaceuticals.

    Like Sylvie said, I think that more transparency would help in situations like these in which pharmaceuticals abuse their ability to overprice important drugs. And like you said, Harsh, the public uproar in this situation is certainly bringing the problem to the attention of many, sending the message that pharmaceuticals have the responsibility to sell their products with reasonable prices. (http://watchdog.org/240577/aids-drug-price-increase-regulations-blame/)

    On a more global perspective, I think that international organizations such as the WHO can have some impact in that they can collect data about the overpricing and underpricing of medicine by major pharmaceuticals in developed countries and assessing the impact of those prices on low-income countries. UN bodies such as the WHO don’t have the power to enforce any regulations on each country, but by releasing this data to the public and broadening access to this information, the organization can help to increase awareness about the unjust overpricing of drugs and put a bit of pressure on pharmaceutical companies to make their drugs more affordable. Such statistics published by international organizations can be used to push forward policy changes that could regulate how pharmaceuticals sell their products, and such changes could start at the public level or government level.

    1. Yuki, thanks for raising that point. Corporations are most definitely able to exercise the kind of power they enjoy because they are enabled by political agency. The FDA regulations and the case of Turing Pharma remind me of the case study we examined in section which followed the narrative of a 10 year old boy in China getting addicted to cigarettes and dying at 37, wherein we all felt the U.S. government had a part to play. In our readings from the Cigarette Century as well, Brandt provided evidence of cooperation between the Tobacco Industry (particularly Philip Morris) and the U.S. government, specially in the case of Thai attempts to prevent the influx of cigarettes from elsewhere. I definitely agree that the FDA has a hand to play in this.

      Related to the pharmaceutical industry, I was reading a news article which talked about big pharmaceutical companies lobbying the U.S. government in order to put pressure on India to change intellectual property laws as they relate to pharmaceuticals so that the manufacture of cheaper versions of drugs (which some Indian pharmaceutical companies engage in) becomes impossible. So this state-corporation collusion is a big concern.

      Also, I think your suggestion for the WHO and other like organizations to act as a dispenser of information is great. However, I can see some problems arising due to the fact that a lot of these organizations are beholden to Western interests and to some extent are steered by political entities who have corporations whispering in their ears.

      On a different note, I was wondering what people think is the motivation for big corporations to keep public opinion in their favor. Given that very often they have monopolies on markets and regulations in their favor, why is it that they succumb to pressure from people, propelled by the media? What are the implications of this pressure and can it be used to make health (not access to healthcare specifically) more equitable on the global landscape?

      1. Harsh,

        You raise a really good point that even UN organizations like WHO can be biased towards Western interests. And that could be a problem because they could present their data and suggestions to pharmaceuticals in a way that works to benefit Western nations. Perhaps it would work if there were multiple organizations checking on and verifying each others’ data and making sure they aren’t skewed, but that could get complicated.

        I do agree with Allison’s comment (below) though, that the government really should be more stringent on corporations, especially those that find loopholes in federal policies and take advantage of them.

        I’m not sure I know the answers to the questions you’re posing, but I think it’s because corporations – while they seem to make unethical decisions – are still made up of people. If enough people raise their voices and lots of negative public attention is brought to the corporation, it is natural to feel pressured and feel obliged to listen to what the people want. In the end, it is still a market system of supply and demand, (and I don’t know much of economics, so please excuse me for simplifying this so much) and the corporations depend on the demand of the people for their supply, so I think the balance of the market is a part of the reason, too.

  3. Harsh, thanks for your post! I had read about this happening, and appreciate the way you connect the readings with current events. I agree that these corporations need to be reigned in, and I too have little faith in “corporate responsibility.” As Farmer points out, certain types of empathy are too unstable to rely on; given that even sincere compassion can only go so far, I am unconvinced that the compassion levels of major pharmaceutical companies will spur any substantive reforms.

    Because of this, though, I would argue that action at the level of national governments, perhaps spurred by international agreements, is necessary to incite change in these companies. As Farmer describes, though people perhaps want to be good, they often need help; if we can entrap ourselves in ethical laws and regulations, then we will all be compelled to act in a way that is morally right, and will further all lead healthier lives. These companies, which have clearly proven their inability to conduct business in an ethical fashion, seem like they would benefit from a similar type of ethics-based regulation. Subsidies, as you mention, are a good way for governments to start and can more quickly provide medications for those in need, but fail to resolve the root of the problem. I also admit that I don’t know a huge amount about economics, so it is totally possible that there are unintended consequences of what I’m saying (as always, thanks anthropology) but based on what I know governmental commitment to intensive regulation seems necessary and beneficial.

    Building off of this, I was intrigued by your comment that perhaps these pharmaceutical companies are the new colonizers, exploiting the suffering and the poor. Yet I would say that the old balance of power and role of Western governments continues to influence global health and politics today. Though operating in a subtler fashion, working through trade agreements (tobacco) and promotion of capitalism (pharmaceuticals) as opposed to outright occupation and exploitation, it seems that the governments of many developed countries are still perpetuating historically familiar inequalities in resources and patterns of power.

    1. Thank you for your thoughts Allison. You’re right in saying that it would be naive to count on the compassion of pharmaceutical corporations. You would expect them to be “responsible corporations” and have differential pricing in order to make medicines more accessible but they seem to be going in the opposite direction altogether by exploiting the poor not only monetarily but in other, more insidious ways such as taking advantage of their desperation to conduct clinical trials for new drugs. One would have thought that after the Trovan expose in Nigeria, which saw 11 children die and dozens others left paralyzed, companies like Pfizer would cease to conduct such operations but that doesn’t seem to be the case. And while I do see where you are going with governmental commitment to intensive regulation, it would seem that corporations manage to find ways to bypass the system (in this case FDA regulations) which is a worrying sign. Another unfortunate part of this story is that the sanctions that are imposed on the pharma companies when they are caught red-handed are monetary in nature, which these corporations can easily withstand.

      I also think the symbiotic relationship between corporations and governments has a big part to play in all of this. Corporations tend to be contributors to political bank accounts and those political factions return the favor by making loose regulations, actively pursuing corporate interests on national and international fronts and under-prosecuting multinationals when they’re in a spot of trouble. How might we be able to disentangle political agency and corporations?

      Certainly, the balance of power between the West and the rest is still skewed and I agree that we still see historically familiar inequalities in resources and patterns of power. With the colonialism aspect, I was trying to draw a comparison between the colonizers of old and the present day multinationals as I feel they have quite a few things in common. They start as commercial ventures, then start gaining political power and misusing it not only to wring money out of people but also to mistreat and overwork labor and exploit the poor. I would like to hear what you think of the parallels I’m trying to draw.

  4. Hi Harsh,
    Your post was very interesting and you highlighted many alarming statistics, such as the huge cost increase of Daraprim overnight. It is very concerning that we live in a world with such severe inequalities and misuses of power, but I do believe that these can be changed.
    I agree with Allison’s comment – it is necessary for national governments to spark a change in the ways these companies are using their power. It is crucial for these pharmaceutical companies to acknowledge the responsibility they have, and to take appropriate action. I think the WHO also plays a major role in this. It is important for the WHO to spark interest and information out to these companies, to benefit those in need – the patients. Taking a step back, it is interesting to look at this in simple terms, in the so-called ‘big picture’ – companies are using people’s health problems as a way to create money. These pharmaceutical companies need to take bigger responsibility for their actions and recognize what is truly at stake – the well-being of people.
    To answer your second question, I think it would be beneficial for places like India to create laws and better educate physicians on prescribing antibiotics, so that people don’t overuse these drugs. I think in order to allow people the access to medication, it is important to establish a health care system that truly helps those in need.

  5. Hi Harsh,

    I think the example of Turing CEO Martin Shrkeli’s price gouging of Daraprim (coupled with his very blatant disrespect for human life in the TV interviews that followed) very masterfully depicts the issue you chose to highlight—well done! The growing power of corporations in determining patient health outcomes (through their control of pharmaceutical prices) speaks volumes about how health care is viewed no differently than any other capitalist market; essentially, big pharmaceutical groups have assigned a value to human life which they weigh against their total cost of producing medication.

    I don’t think there’s a foolproof answer to your first question since states may be limited in their ability to instill a sense of social responsibility in such companies. Granted, there are some actions that can be taken against price gouging but each has its own unique issues in practice. One example is setting binding price ceiling on the maximum price of a pill such as Daraprim—this would ensure that the market price charged for Daraprim could not be higher than some established level. Still, there’s no way of truly accurately calculating the paying capacity of a consumer that requires this medication, and even if such a price were to be found, companies like Turing could pull back on its production of the drug and create a shortage that would burden consumers more than it does producers.

    In response to your second question, ideally, doctors and other medical professionals should be tasked with educating patients and family members about the importance of daily dosages and should (to the best of their ability) follow-up with their patients to ensure prescriptions are being followed. Yet, this becomes a little tougher to implement in practice if governments don’t somehow incentivize doctors to do so.

    I believe pharmaceutical companies often succumb to the pressure of the public because they underestimate consumer resilience and elasticity to price spikes. Often, this can be used to ensure companies don’t overstep their boundaries when charging patients; this can be used to make health more equitable up to a certain limit, beyond which companies would be guided more by their own self-interest and would continue to raise prices for their production. This is clearly the case for Turing—Shrkeli seemingly gave into public outcry over his price gouging and promised to reduce the price of Daraprim back to its original level but it appears now that he has had a change of heart (http://www.businessinsider.com/martin-shkreli-update-on-daraprim-price-2015-10).

    1. Thank you Sachit. I agree that there isn’t a foolproof answer to the question I posed. Your analysis of the situation got me thinking of another facet of this issue, that of medical research and intellectual property rights. One of the reasons the Daraprim case caught people’s attention was because the company has managed to monopolize the production of the drug even though its patent ran out years ago, by moderating distribution carefully and not allowing competitors access to the formulation of the drug. Putting Turing aside for a moment though, do you think it is ethical to have patents and such for medicines which allow corporations full control over a drug? If intellectual property rights were to be revoked for medicines, do you think it would adversely affect medical research and the development of new drugs? Can we count on people’s sense of compassion and altruism to propel enquiry in the field of medicine?

      1. Hi, Harsh!

        I think the Daraprim case is unique in that its CEO very openly prioritizes his corporate interest over his responsibility to provide medications to vulnerable people (here’s an article that demonstrates just that– http://www.chicagotribune.com/business/ct-turing-doubles-down-1205-biz-20151204-story.html). To answer your question, I’m not sure if it is ethical to have patents for such medicines but I do believe that patents are important incentives for companies to invest in medical research and develop new therapies. At the same time, government agencies need to be able restrict the market power that some corporations exercise over their drugs because, as we have seen time and time again, corporations rarely uphold their ethical obligations to serve at-risk patients when doing so comes at the price of profit.

  6. Hi Harsh,
    Thanks for a great blog post about this topic; I, like the others who have commented, have also been following this story. It was nice to get another take on it. As for updates on the case, I know that CEO Martin Shkreli released a couple of statements about making adjustments to the price. He, unfortunately, has yet to do so (http://www.businessinsider.com/martin-shkreli-update-on-daraprim-price-2015-10).

    I’m not sure if states can play a leading role in inducing change in legislation because, under the Constitution (Commerce Laws), any type of interstate commerce must be regulated by the federal government. This means, essentially, that as long as consumers are willing to pay for a product, the pharmaceutical companies will be able to continue manipulating prices. Also, the WHO cannot directly intervene because each country has its own regulating policies. Thus, change must come from the federal government (perhaps the FDA). But, as Yuki commented, the FDA has essentially put a cost on the production of the same drug by other pharmaceutical; in addition, importing Daraprim from foreign countries is also not allowed. So in terms of legislation, a bill from Congress would have to be submitted to bring about change in the FDA.

    Like Sylvie mentioned, I think transparency and awareness among consumers and distributors/producers are essential in inducing pharmaceutical companies to recognize their social responsibility. Once people – especially the consumers – have access to this information, they can have a revolutionary influence on the media and thus on the heads of corporations (this is something both you and Sylvie mentioned). However, I do doubt the media’s ability to bring about actual change; as I stated above, Turing still not has lowered the medication’s price.
    I also am concerned with leaving this burden in consumers’ hands. On one hand, the majority of people would probably agree that a 5000% price hike on a drug is not ethnical. But on the other, how many are willing/able to lobby against pharmaceutical lobby groups? In addition, one could argue that if the price is too high, people should not purchase it (boycott it); this would force companies to lower the price. But how can we ask people who need/can afford this medication not to buy it?

    I would like to share what Shkreli has to say about the decision to raise Daraprim’s price. He has mentioned in interviews and on social media that raising the price of Daraprim has good consequences: people who have heard about this drug are now interested in researching toxoplasmosis, which, he argues, has been largely ignored. In addition, he says that extra money will help develop an ocular form of Daraprim (http://mediad.publicbroadcasting.net/p/wabe/files/201510/Shkreli_Transcript.pdf). Do you think there is any validity to his argument?

  7. Hi Harsh,

    Thank you for bringing up such an important issue of inequality in medicine. I had also heard about the drastic rise in the price of Daraprim, and your blog post allowed me to have a much deeper understanding of this situation, as well as the entire problem with pharmaceutical corporations overall.

    I wanted to explore the “web of blame” we previously talked about in section. Many of us had differing viewpoints when it came to deciding who was more to blame when it came to the issue of tobacco–corporations, or governments (or the many other people/groups listed). I think the same ideas can be applied to pharmaceutical companies, with the additional layers of taxes, capitalism, and funding. Based on my findings, the United States has the “third highest general top marginal corporate income tax rate in the world at 39.1 percent” (http://taxfoundation.org/article/corporate-income-tax-rates-around-world-2014). This pressures many corporations to raise the prices of their goods (though I still believe Turing Pharmaceuticals’ price increase was extremely unwarranted) simply to stay in business. Said with my limited knowledge of economics, I feel as though the government has the power to lower corporate taxes and, like Sachit mentioned, to place a price ceiling on goods, but this becomes complicated when trying to determine why the government hasn’t yet done this. It may be that the idea of capitalism is a strong component of the U.S. and setting price limitations in general could cause backlash. However, I am sure there are many other factors and reasons unknown. Funding for research is also an issue that weaves together governments and corporations. Limited government funding for research on drugs can hinder its progress, not to mention the time required to thoroughly conduct the research and the regulations that need to be surpassed. Due to this, a company would be forced to turn to private funding, allowing for a monopoly over the drug.

    On your point of intellectual property rights, we need to take into consideration what motivates people in the research field. With my experience in biological research, I have noticed that there is an overwhelming push to publish, and I would assume it would be similar in gaining intellectual property rights. Scientific research also pressures researchers to be the first to publish, and to essentially be the pioneers for discovery. This allows for recognition–a strong driving force for humans. Relying on altruism can be naive, and though I’m very sure there are many people who are motivated to research with the sole purpose of helping others, progress would be much slower without the monetary motivation and recognition associated with getting results.

  8. Hi Harsh,

    Thanks so much for sparking this really interesting discussion. This is actually something I’ve been thinking about a lot recently. This summer, while working on Global Health Policy at a think tank in DC, I was in the midst of the TPP Protests. Your first question is a very good one, but also very difficult to answer. While I think it was a great first step that people were actually protesting the TPP decision on the hill, it was unsuccessful. Clearly there needs to be more than just public outcry. I think politicians and those with legislative power are the ones who need to be spearheading a movement towards greater transparency, more regulations that enforce equal access to medications, etc., but I’m honestly not sure how realistic this is. The system is so complex–there are so many players–governments, donors, pharmaceutical companies, researchers and developers–and the financial power and legislative power that these big pharma companies is so real. After this summer, I’ve made an effort to try to understand these issues better, but even now I am still pretty confused. While I don’t think education programs can ever really be a fix-all solution, it would be beneficial if more politicians and people in general knew about the policies and regulations that are involved in drug production and distribution. As Yuki mentioned before, the pharmaceutical industry is indeed a profit-driven industry, and if there were to be public outcry about these issues of inequality, perhaps rules, regulations, and practices would have to change in order to sustain profits. I think the TPP protests show that perhaps we are starting this process, but we have a long way to go. In a working group meeting with Sanofi Pasteur on vaccine ecosystems, I saw that there definitely was at least some transparency about the challenges pharmaceutical companies face with ethics and gaining profit from drugs that are indeed expensive to develop. I wish I could give you an answer that actually solved the problem, but unfortunately I don’t have one (kind of depressing). I think steps that we can take are informing the public, and hopefully then politicians might get more involved to appease constituent upset and outcry. With more involvement from American legislation, hopefully this would then spark international laws and regulations that prevented these (mostly American) pharmaceutical companies from making drugs unaffordable and therefore inaccessible to people who need them.

    The second question that you raised was very interesting, and something that I haven’t really ever thought about in a global context before. When people go to the doctor, they want a diagnosis and they want medication. I have gone to health services on several occasions with undetermined illnesses and have been prescribed Z-packs. This problem of antibiotic resistance comes from both the doctors, the patients, and the culture of health that we’ve developed. I am by no means calling doctors evil or saying that they have ill-intentions, I think over prescription of antibiotics comes from really good intentions–they just want to put patients out of suffering. However, down the line this could have a really negative impact on population health. Perhaps education programs on antibiotics and how to take them appropriately could be helpful. Perhaps there could also be more regulations as to when doctors actually prescribe antibiotics (after getting a positive test of a bacterial infection?). I definitely don’t think that access to these medications should be limited because of the growing misuse and misprescription of medications because antibiotics are very important (and a very simple solution) in treating infections that could be life threatening without any medical action. I think the most important thing we can do to allow people access to medication while also preventing them from misusing it is by creating stricter prescribing policies so that patients are receiving appropriate care. This can be problematic though if it is hard for a patient to actually see a doctor, and therefore can’t access necessary medication because they can’t access a doctor to prescribe it to them.

    These are both very tricky, complicated questions. Thanks for asking them. They’ve certainly got me thinking a lot…

    -Rebecca

  9. Hi Harsh,

    The parallel you made between colonizers and corporations was really striking and something I had never considered before. Whether we’re talking about pharmaceutical companies exploiting developing countries and poor populations in order to profit, clothing companies that rely on essentially slave labor to make their products, or corporations that create pollution and rob people of their land’s resources these cases really don’t differ from early colonists agendas. And even the political power wielded by these companies through backed support by government officials, at least in the case of the US, analogs the similar political power of old colonial empires.

    Similarly to what several classmates proposed above and what we discussed in our first section meeting, I think the burden of social responsibility resides in these companies to make ethical and moral decisions regarding their pricing and the process of making their products. Even more than the companies we find at fault for marginalizing poor populations and exploiting their consumers, I think are state governments and international organizations like the UN because these are the governing bodies that create an environment for corporations to prosper and continue their unethical practices without repercussions. And even beyond that still, education, transparency, and adequate resources for the public are essential to regulate corporations and prevent them from abusing their power, at least in democratic countries (these resources should obviously still be provided in countries without the ability to vote). Maybe this is idealistic for me to say in the case of the US and the recent questioning of the integrity of its political structure but in the end aren’t citizens in charge of who is elected to office and who is making these decisions that directly impact our lives and the lives of people around the world? I think a better informed and engaged public would put pressure on pharmaceutical corporations to reconsider their responsibility of providing equitable access to drugs globally.

  10. Hi Harsh,

    I found you blog post very insightful and informative. I had heard of the huge price increase of Daraprim and am still under shock every time I hear about it. How can a drug go from $13.60 to $750 a pill?! But that is the reality of pharmaceuticals and Daraprim is not the only drug going through drastic price increases. The different topics you covered and examples you used clearly show how drastic health inequality and its impacts can be.

    Concerning your first question, I do think that pharmaceutical companies do not recognize their social responsibility and the impacts of their actions. These companies know how essential their drugs are to many people around the world and that some people need it to survive or feel better. The best way to make them recognize the cost of their action can only be done through awareness and education of these companies by showing them what the impacts of their price rise are. As you and Yuki mentioned, a public uproar might increase the public awareness of the current issue but I am unsure of the actual lasting change it could bring. On the other hand, I think that this is where big international organizations such as the World Health Organization or the FDA play a big role. Because they are very important in the health industry, they could set up regulations and interventions in order to stop the price increase and raise awareness of each company’s action. Although this is a very unrealistic idea, I do think that they play a major role in this industry and that they could produce a major lasting change.

    As for your second question, I think that overuse and misuse can be prevented by government regulations as well as an increase of awareness and education of the population and of physicians on what are antibiotics, when to use them, what are the impacts of misuse …
    I also think, as Yuki and Sachit mentioned, that pharmaceutical companies do feel pressure from people when they are propelled by the media because of the elasticity of price and demand. I think that one main reason is that when they are under the spotlight, more people are aware of the price change and this might decrease the demand, which in turn will force them to decrease their prices.

  11. Harsh, thank you for your insightful twist on this week’s readings! I find the discussion around the power of corporations something people are either passionate about, or don’t want to speak about. I often forget the power corporations have over health, which speaks about the nation and area I come from, since the consequence of this specific incident with Daraprim doesn’t affect my daily life.

    I think the point you made about tobacco companies and pharmaceutical companies allows for easier understanding and comparison of the problem. The tobacco industry was only exposed out of public outcry of the harms of tobacco. There was an entire cultural shift that drove many tobacco companies to seek international markets. Since the tobacco industry and the pharmaceutical industry are both driven by profit and don’t seem to be concerned with the people they’re serving, could the same movement work for the pharmaceutical industry I wonder? If public outcry formed the pharmaceutical companies to realize their social responsibility and provide access to more equitable drugs, this likely might only happen in developed countries. Then the same international markets would likely be tapped for profit, because people in developing countries have less of a voice when it comes to world markets. So could these pharmaceutical companies every actually create equal access to drugs? Who leads pharmaceutical companies, and how could that leadership change to one that’s more socially aware of what their drugs truly do?

    I think this idea of allowing people access to medication and preventing them from misusing it would go well with the healthcare principle of co-pays. In the US and many other countries, copays are used to deter people from going to the doctors all the time. Copays are scaled towards income, so people have to pay some money, but it’s not enough to burden them, and not too little that they misuse the service. I wonder if this same principle could be applied to drugs. Those who have more money would pay more, and those who have less would pay less. Pharmaceutical companies could still gain money from the wealthier people, but the price would still be manageable for the poorer people.

    Something that I would like to touch on is that corporations have a lot of money and, therefore a lot of lobbying power. I remember reading an article about a non-profit that was trying to pass a law that wouldn’t require fire retardant to be in furniture, as it’s toxic. Some corporation they were going up against flew in 4 young boys to testify on the stand how they didn’t want to burn in the fire and die. This is why it’s so hard to combat corporations, because of the money they have from focusing on just the profit and harming many people in the process.

  12. Thank you, Harsh, for inciting a great discussion about the role that pharmaceutical companies could play in increasing patient access to medications. It is true, as many have noted, that these companies are corporations that aim to reap profits from their products. Yet, as Sylvie emphasized, there’s more to this problem than just cost. We must make medications more accessible by decreasing costs in conjunction with increasing communication, transparency, and consumer awareness. Patients would then, hopefully, understand whether or not they are paying reasonable prices for the drugs they need. Yet, to what extent will patients truly understand the reasons behind the price of a drug? How can we measure patients’ understanding of overpricing?

    I’m also wondering whom we can look to for this desired change and how they can realize it? International organizations, such as the WHO and the UN, generally do not have the “teeth” to enforce policies. Echoing Allison and Julianne’s comments, I believe governing bodies within individual countries will have to take on the task of enforcing policies to restrict pharmaceutical companies’ seemingly unrestrained power on the price of their drugs. Particularly, actions in the U.S. would need to move quickly because the demand for personalized medicine is increasing. Personalized medicine, relying on biological markers to identify patients who will respond in a differential manner to treatment protocols, gives people the opportunity to receive optimal, individualized treatment. However, this request for a customized drug means that the drug will be inherently more expensive because of the costs associated with manufacture. Are these extreme increases in price appropriate? Thinking back to Thu’s point that the U.S. has the world’s third highest general top marginal corporate income tax rate, whom should we hold responsible for the cost of drugs?

    Your second question, which urges us to think about the converse problem, is harder for me to address. Antibiotic and antimicrobial resistance presents a great threat to the health of a population because the resistant strains can spread from person to person or from non-human sources. My first instinct is to encourage doctors to avoid prescribing antibiotics unless they are truly needed and then to confirm that bacteria are causing the infection. The latter may require laboratory tests, which brings us back to the problem of affordability. As Katherine suggested, co-pays may curb the demand for antibiotics for viral infections, but patients who do not understand the biological basis of disease may see this cost as another barrier to seeking medical help. In essence, you have raised many questions – none of which I think I have a satisfactory answer for.

  13. Harsh, great job shedding light on this. I find everything about this exploitive, inhumane, and shameful. In the case of the company that acquired the rights to sell Daraprim, I find their actions deplorable and mercenary. But in the greater conversation of overpriced pharmaceuticals, I just don’t know if I want to object to any of it. When I consider the billions of dollars that are poured into R&D, and the sheer talent these companies have to attract (monetarily incentivize), it’s not hard to reason why the pricing is what it is. The drugs that major pharmaceutical companies are, if you wanna get poetic, pretty miraculous in my opinion. I can appreciate the sentiment that many hold with regard to how unreasonable the prices of some of these drugs are, but if the opportunity to demand these prices was never presented to these companies, would the drugs exist today? Well, are these corporate opportunities available in Africa? No. Likewise, they’re also not developing effective drugs.
    I’m torn between idealism and capitalism. Both produce good in the world. But one produces tangible goods–the advent of the computer, modern medicine, air travel. I don’t think you can be an idealist if you’re a capitalist, and vice versa. I also don’t think picking a side at either extreme is the right answer. The answer falls somewhere in the middle. Perhaps I lean closer to capitalism.

  14. Hello everyone,

    Thank you for taking the time to read my post and sharing your thoughts. I really appreciate all the feedback you have given me.

    I submitted my blog post early in the semester and since then we have discussed pharmaceuticals in many different contexts (the pharmaceutical fix, the right to health, medicalization of social suffering, clinical trials, etc). While all of these discussions are relevant I would like to highlight a couple of things regarding pharmaceuticals that we went over in class and how they relate to my original post and the questions I posed for commentary.

    Firstly, I think realizing the unique nature of pharmaceuticals and their place in global health initiatives today is important. This takes me back to our discussion of ‘the pharmaceutical fix’ wherein we talked about pills being the ultimate magic bullet. Perhaps, the best representation of this are the following pictures that we have seen time and again in lectures.

    http://skollworldforumorg.c.presscdn.com/wp-content/uploads/social_edge_images/070717_MedEx_jeunebefore2EX.jpg
    http://cdn.skollworldforum.org/wp-content/uploads/social_edge_images/070717_MedEx_jeuneafterEX.jpg

    While the McKeown hypothesis suggests that an epidemiological transition cannot be achieved through public health initiatives, there have been instances in which using pharmaceuticals has led to significant improvements. Perhaps the best example of this is the use of HAART to tackle HIV-AIDS.
    Be it their visible effects or the ease of administration, pharmaceuticals have become an important part of the global health landscape and many organizations have become organized around their distribution. This of course has given pharmaceutical manufacturers (the corporations) a lot of power, which essentially formed the subject of my blog.

    Turning to the latter of my discussion questions, in a similar vein as rising antibiotic resistance due to over prescription of antibiotics, providing access to pharmaceuticals has had unanticipated consequences. For instance, in Brazil, where the government started providing ARVs as a part of the right to health, the price index of medicines was found to be 13.1x of the world index. Likewise, in our reading about Plan AUGE in Santiago, Chile, we got to know that people were misusing the anti-depressants being prescribed. While the morality of this is a bit of a grey area, it is quite clear that access to pharmaceuticals has many nuances and isn’t a simple problem with a single correct solution.

    In your comments, a lot of you have put forwards ideas that are worthy of attention, ranging from using government enforced price ceilings to make medicines affordable and accessible to all, to using the system of co-pays to minimize misuse of pharmaceuticals. All of these are viable options, however, they are bound to have unanticipated consequences and their implementation will be highly variable and context specific.

    Having said that, I think the importance of pharmaceuticals is justified and as seen in the case of HIV-AIDS treatment with ARVs, pharmaceuticals can be effectively deployed to counter global health challenges.

    1. Hi Harsh,

      While pharmaceuticals have proven to be effective in some contexts, there are many situations where they have downgraded global health. I believe that the government plays the most important role in adjusting and overseeing actions of pharma companies. In your last comment, you mentioned the unanticipated consequences of intervening governments in such contexts. What are potential unintended consequences, and do these consequences outweigh the positive aspects of the government’s intervening?

      1. Thank you for you question Julianne. I agree that the ‘pharmaceutical fix’ isn’t always the answer when it come to solving a health issue, but the motivation for my post was that it has increasingly become the preferred solution in global health circles today.

        Some of the unintended consequences of government imposed control on pharma companies may be that investment and innovation in the industry might be stalled and over time these companies may choose to downsize production of unprofitable medications (which are most likely to be of the essential variety). This article – http://www.ibtimes.com/should-government-control-price-prescription-drugs-2112771 also asks the same question to some extent and addresses the risks of imposing price ceilings, etc. You might remember our discussion of why pharmaceutical companies did not like the WHO’s Essential Medicines list. Govt. control of pharma would be a few paces further in that direction.

        In response to your other question, I’m uncertain as to whether the pros of government control outweigh the cons as it will have very different effects depending on the context. We have seen examples of countries where govt. distribution of medicines has had negative consequences (the cases of Santiago, Chile and Brazil come to mind).

        1. Harsh,

          Thank you for your response. That article is very interesting and explains these consequences well. I think you bring up a great point in that investment and innovation may be stalled. Also, I agree that the “pharmaceutical fix” is the preferred solution, and as there are some unintended consequences, there have been many positive aspects from this ‘solution.’

  15. Hi Harsh,
    Thank you for taking the time to write a thoughtful update on your blog post, where you do a great job talking about the role that pharmaceutical companies play in increasing health inequalities and preventing economic access to medicine.

    When we look at the economic rules that govern capitalist business institutions, we see that most are governed by the general principle where prices will rise as demand rises and competition is not a factor. As Yuki mentioned, for many pharmaceutical drugs available in the US, the FDA is to blame for lack of competition. But even going further than that, I fundamentally believe that healthcare does not follow the standard supply and demand pricing model of capitalist economics. There is no price when someone whose child is dying of a disease suddenly decides they no longer want a certain drug. Rather, demand for most medicines is almost completely inelastic, and to hugely profit off of the desperation of others is immoral at best. I think we need to have a larger global dialogue about how we can continue to “encourage innovation” in the drug creation and manufacturing process, while acknowledging that there is no true “market price” a novel drug can have that will likely affect demand for those who are able to get their hands on that sum of money. I liked in your comment response to Allison where you mention how a “differential pricing model would be the ideal to make medicines more accessible, so that people can pay what they can afford while a drug company can operate under a more profitable framework.

    In regards to your second question, I would push back on your assertion that “underpriced medicines can be [a big problem] as well.” It is not the price of any drug that is the problem, but the lack of knowledge of correct usage surrounding the medication that is causing harm. I think the only way to prevent misuse and enforce regulations to ensure doctors have up to date information and are constantly reminded of why common health care prescriptions and abuses are extremely dangerous on a population level. Overall, I think you did a great job of exploring the nuances of the difficult question of pharmaceutical regulation.

    1. Thank you for your thoughts Alana.

      You’re right, the low prices of drugs are seldom the problem themselves. It is the lack of knowledge about correct usage that is the root of the issue. The reason why I put forward my argument the way I did was because coming from India I have often seen people purchase medication that would require a prescription in US, over the counter at a drug store. A lot of people self medicate and in many cases they misdiagnose or overmedicate which causes more problems. The government of India has tried to curb this but so far has been unsuccessful. While I appreciate the government’s move to make medicines more accessible by providing subsidies on many medicines, it has caused unintended consequences of its own as many people, especially from poorer section of society, don’t have the resources to obtain healthcare through the appropriate channels (healthcare providers, doctors, etc.).

      It then becomes a question of whether people shouldn’t be allowed to buy medicines if they’re desperate or whether they should be allowed to get medicines and potentially cause self harm.

  16. Hi Harsh!
    I thought your post mentioned some really interesting facts about pharmaceutical companies! I mentioned your post in mine!
    To answer your first question, I think that states should either invest in little mopeds or motorcycles like in the recent film we watched in class. They are relatively inexpensive and the organization helped train villagers how to use and fix the bikes, which would create sustainability. Otherwise, I think promoting more barefoot doctors to go from house to house to help ensure that people are taking their drugs adequately would be a good idea as well. The WHO could help compensate by giving small donations to the barefoot doctors or even allow them to have free access to some of these medicines.
    Your second question was brought up in my comment section, and I thought that it was an interesting problem to address. Like I said in the previous question I think that incentivizing for more barefoot doctors would help ensure that people were taking their drugs as they were prescribed. I think the government should also enforce regulations on drugs based on the incomes of the population they are selling to.

  17. Harsh, you bring up some really interesting issues – and I want to comment on one more philosophically and the other more pragmatically.

    How do you get pharma companies to act ethically? Its like asking how do we negotiate capitalism, or attempt to adjust it to work in whatever ways we feel are most equitable – it sometimes feels inconceivable, but challenges to capitalist consolidations of power and to harmful business practices has always been the job of the people. If we can turn this issue into something translatable to the public, then we can illuminate exploitative practices and injustice, and hopefully produce a social movement that could put enough pressure on companies and governments that they might alter their behavior. Asking for a social movement might seem farfetched, but the power of the people should not be underestimated and history shows that this power can bring about the kind of change you are discussing in your post. While some commenters have expressed doubt about public protest as a strategy, its one of the only options left to us in a capitalist system. We could remake the bed and socialize medicine… Otherwise we have decided that health is a business and everything is for sale.

    In response to your second question, antibiotic resistance is an unanticipated consequence (yet somewhat more “anticipated” now that we have frequently encountered it) that can be difficult to resolve because we do not want to restrict the use of really important medicines that do a lot of good and are pretty inexpensive. DOTS seems to be a good model. Communities greatly impacted by this issue could benefit from systems of voluntary or paid health workers who can ensure people’s daily, proper use of medications and also provide them with basic health education. I think that uncontrolled or unregulated antibiotic distribution is more harmful than beneficial because these medications can be made so widely available by clinics and hospitals due to their low cost. National governments should be focused on ensuring basic antibiotic regulations wherever they are distributed. There should be greater awareness about the dangers of antibiotic resistance and misuse of the drugs, and there should be a focus on eliminating cites of access that are unregulated. Additionally, preventive and primary care should continue to emphasized to reduce bacterial diseases and the great need for antibiotics.

    1. Thank you for your comment Elena.

      Your thoughts on getting pharmaceutical companies to act ethically do strike a chord with many of us. In fact the example of Daraprim (please see the update below) shows that even if public outcry may not affect the actions of one individual, it certainly has the influence to motivate other actors (pharma companies) to address the issue. The decision made by Express Scripts and Imprimis Pharmaceuticals is a good example of this. I sincerely hope we never come to a point where, as you put it, health is a business and everything is for sale.

  18. Hello everyone,

    Here’s the latest on Daraprim –

    After extensive coverage and backlash in the media, Martin Shrkeli has reduced the price of the drug to $350 per pill for hospitals. But for individuals, who can only buy the medicine at a Walgreens, the price remains at $750/pill.

    Some of the comments made by the Turing Pharmaceuticals manager on this issue include –

    “I would have raised prices higher, that’s my duty.”

    “My shareholders expect me to make the most profit, that’s the ugly, dirty truth.”

    “I’m going to maximize profits,” that’s what people (in health care) are afraid to say.”

    However, in a positive vein, Express Scripts, ( the largest pharmacy benefits manager in the US) has announced that it will be collaborating with Imprimis Pharmaceuticals to develop a new drug to treat potentially fatal toxoplasmosis and provide patients with an alternative to Daraprim which will cost $1.

    http://www.chicagotribune.com/business/ct-turing-doubles-down-1205-biz-20151204-story.html

    http://www.techtimes.com/articles/112630/20151206/express-scripts-partners-with-drug-compounder-to-provide-1-alternative-to-daraprim.htm

    1. Hi Harsh!

      All I can say is wow! I can’t believe that a pharma company would price a drug so high. I wonder how many people actually will buy this drug. When do you think pharma companies cross the line, and government needs to step in? What do you recommend, and why?

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