Brexit, Cystic Fibrosis, Democracy, Diabetes, GE2019, Health, Healthcare, Jeremy Corbyn, Labour, Medicines for the Many, N.H.S., National Health Service, Opinion, Orkambi, Politics, Public Health, Regenerative Medicine, Research and Development, Stem Cell Research, Technology, Type 1 Diabetes, Vertex Pharmaceuticals, Viacyte
One would think that a cliché is untrue simply by virtue of being a cliché. According to the electioneering Labour leader Jeremy Corbyn, the National Health Service is in danger of being sold off to greedy, villainous US capitalists. Corbyn warned in parliament last week that, “Our NHS is up for grabs by US corporations in a Trump trade deal. This Government is preparing to sell out our NHS.” In response, an exasperated Tory health secretary Matt Hancock tweeted, “How many times do I have to say this? The. NHS. Is. Not. For. Sale.”
Given the anti-Semitism that is currently chewing up his party, Corbyn might be wiser to place a less conspiratorial emphasis on his defence of the NHS. He is not claiming that the Jews are stabbing the NHS in the back – rather, it is merely a sinister minority of secretive financiers. Sure, anybody on the far right might find this story to be instantly familiar, but this does not, by implication, make it a far-right story. The aesthetics of Corbyn’s conspiracy-mongering are indeed getting in the way of him properly recounting the politics.
That the NHS is “for sale” is Corbyn’s slogan but you have to jig this around a bit before you can unlock its ultimate meaning. Corbyn fears that drugs might be soon sold at such a cost that it will be the NHS itself that is unable to buy them. The NHS might emerge from post-Brexit trade talks having to pay an additional £500 million per week for medicines. Is this a paranoia that is worn lightly, as a cynical electoral stance, or is it instead a rational reaction to the growing power of private finance within and over our public services? And as the cost of medical technology rises, and becomes ever steeper for those with rare diseases or conditions, is there any model of funding available that can see the NHS through future supply crises?
There might be a certain level of raw cynicism bolstering Corbyn’s standpoint. He probably knows that he has never sounded warm or even interested in the EU that his party is supposed to be defending. For most of his career, he has been routinely Eurosceptic. Pinning the privatisation of the NHS to post-Brexit trade deals is perhaps an innovative way for Corbyn to try to locate or renew a personal passion for being against Brexit. Even so, Labour’s recent policy paper Medicines for the Many remains commendably open-minded about the role that the EU plays in undermining universal access to expensive drugs. It concedes that certain protections for drug companies are “are enshrined in EU regulations” and that “Brexit might present an opportunity for the UK to move away from these EU rules.”
As Medicines for the Many admits, the NHS has been already paying exorbitant prices for drugs as a default setting and during our membership of the EU. ““In 2018,” the paper notes, “NHS England paid £18bn to the pharmaceutical industry for the drugs it prescribes to patients, a figure which has been growing at a rate of around 5% per year [this figure has been since disputed].” Insulin is one of the biggies here. The NHS at present pays £404 per person annually for insulin, whereas a 2018 study from Health Action International had looked at the feasible alternatives and nominated any number between £36 and £54 as a saner figure. Given that insulin’s price is now five times higher than its manufacturing costs, maybe Dior or Armani should market it as a designer accessory.
At this year’s Labour party conference, Corbyn took up the case of Luis Walker, a nine-year-old sufferer of cystic fibrosis who had, until very recently, been unable to gain access to the new wonder-drug Orkambi. Only around 5,000 people in England will potentially benefit from Orkambi, and it is a reassuring sign of how humane our politics is that Corbyn has chosen to thrust such an obscure injustice into its forefront. And it is certainly disconcerting that Orkambi has been withheld for so long from the tiny minority of sufferers who need it.
Vertex Pharmaceuticals, the manufacturer, had secured regulatory approval for Orkambi in 2015. But it took four years for NICE to agree a price that the NHS could responsibly pay. These negotiations do seem rather surreal. Vertex had spent billions of dollars researching and developing the drug, of which the overwhelming majority had come from investors who were expecting a return. In its standoff with NICE, however, Vertex had announced that the price wasn’t to its liking and that it wasn’t selling. This price, incidentally, was described by the NHS as the “largest ever financial commitment” in its history. Yet NICE are Vertex’s only customers in England and if NICE aren’t buying, then there is no elsewhere for the company to go. Orkambi would cost a private patient £104,000 a year and the patients who could afford to pay this would not amount to very much of a queue in the chemist’s.
Nevertheless, in March Vertex had destroyed 7,880 out-of-date packs of Orkambi, each containing a month’s supply. This was obviously maddening for the intended recipients, especially given the endless discomfort and claustrophobia of their condition’s symptoms. Finally, in October, NICE and Vertex engineered a confidential “flexible commercial mechanism,” under which three of Vertex’s drugs, including Orkambi, would be available for prescription on NHS England. This deal is estimated to be worth about $500 million per year to Vertex. Jeffrey Leiden, the outfit’s CEO, had taken home $18.8 million in 2018, though it will be some consolation to the families of those who have died from being unable to access his company’s products that he was only subsequently the 11th top-paid boss in the pharmaceutical industry.
If I was in the unfortunate position of working for Vertex, I could almost imagine brainwashing myself into believing in the moral urgency of its high prices. If my employer does not get these fees, I would tell myself, then who else is going to cure cystic fibrosis? When one climbs inside this utilitarian mindset, NICE begins to look morally unimaginative in seeking the short-term benefit of low-cost drugs, at the expense of alleviating greater harm over the long term. The current generation of sufferers becomes a noisy distraction. Those campaigning for lower corporate salaries and greater transparency are similarly taking the wrong side in a vicious struggle in which the end justifies all means. Perhaps I could be mentally at peace by telling myself this.
Let us jump in here and consider how things would have played out under a Jeremy Corbyn alternative government. Corbyn claims that he would have forcibly stripped Vertex of the patent for Orkambi, with Crown use licensing, and that this patent would have been awarded to another manufacturer to produce a low-cost generic alternative. To be charitable to Corbyn, the mere threat of doing this would have been probably enough to bring Vertex scampering meekly back to the table. But supposing that Corbyn had followed through on his threat.
There is firstly the question of how quickly the new generic drug could have been manufactured. There would be naturally a delay in supply, during which the government would be no longer negotiating with an already tooled-up supplier, and so production of the new drug would need to run very smoothly and quickly for it to enjoy ongoing political confidence. The case of Civica Rx, which was set up in 2018 by hundreds of American hospitals to manufacture generic drugs, is here ominous. Although it performs worthwhile work, as a kind of club for buying medicines, it has since downgraded its ambitions of becoming an independent pharmaceutical manufacturer.
Secondly, the government might be eventually forced to compensate Vertex for seizing its intellectual property. The price of this compensation would be presumably set at the figure that the state had been originally trying to barter down. If there was any risk of this at all, then there would be no point in invoking Crown use licensing.
There would be thirdly, and far more problematically, a huge commercial deterrence to Vertex to continue researching newer and better products. Orkambi is not the end of the story. At the same time that Orkambi had become available in England, it was being superseded in the USA by a new drug, Trikafta, which is apparently even more miraculous. Following what Vertex would see as the legalised theft of its property, its Trikafta would be not bound for England any time soon.
(I’m aware that in Edinburgh the relentless use of the word “England” might grate on many readers’ ears. In a good example of pointlessly devolved bureaucracy, Scotland has its own version of NICE that had bungled its negotiations with Vertex, paying, by all accounts, considerably above the price achieved in England. Splitting the UK’s purchasing power in this way inevitably gives both nations less leverage in their negotiations with big pharma).
Medicines for the Many argues that the state already invests so heavily in medical research that there are not many more steps until it reaches outright nationalisation. But this sounds like an idea for another day, considering that the UK economy is not currently generating anything like the tax revenues that would be needed to fund, say, mass clinical trials for stem-cell therapies. Most international medical R&D is done in the USA, where the private sector claims to spend a cool $150 billion per annum on new tech. Furthermore, a great deal of this figure pays for experiments that bomb and for knowledge that doesn’t have any immediate application. Contrary to Heidi Chow’s assessment of the status quo in Jacobin Magazine, nationalising medical R&D would be genuinely socialising risks, and at a cost that would be unlikely to command long-term democratic support.
There is a certain naivety underlying the distinction that is made between public and private research in Medicines for the Many. The paper depicts private pharma as a reptilian world in which everybody is chasing huge salaries. A publicly owned pharmaceutical company would, though, be just another pharmaceutical company and it would have to compete with the private sector for expertise. If it paid lower salaries, then it would be wilfully second-rate, unless, that is, all of its staff were somehow happy to waive the market price of their labour. This seems a reckless hope to hang such an important public investment upon.
Likewise, Medicines for the Many claims that private pharma is characteristically short-termist and always looking for the quickest route for big bucks. It is correspondingly implied that public pharma would devote itself to expensive, long-term research into little-known diseases. In reality, with a minister constantly breathing down its neck, the state-owned pharma would be prioritising a cure for male pattern baldness along with every other private company. There is no inherent reason why a state-owned company is relieved of the same squalid commercial pressures that bedevil the private sector.
This article might be lighting the way to fatalism or to a resigned acceptance of a status quo in which lots of patients needlessly suffer and die. There are in fact numerous outlets for progressive government action that are recommended in Medicines for the Many. The state can legislate or even litigate to prevent “evergreening,” or big pharma’s tweaking of products in order to gratuitously renew their patents; it can impose commercial conditions upon the recipients of medical R&D funding; it can intervene to award prizes in fields of research that are typically neglected by private laboratories.
The best funding model so far developed, the California Institute for Regenerative Medicine (CIRM), had involved California’s taxpayers deciding in a 2004 referendum to give $3 billion of their cash to private start-ups and non-profit organisations. CIRM is not mentioned once in Medicines for the Many, which is peculiar considering that it is such an eye-catching landmark of combined private and public innovation. CIRM has resulted in 56 clinical trials and it has made $10.7 billion in sales revenues. If anybody is going to decisively cure type-1 diabetes, it will be ViaCyte, who is using funding from CIRM (and many others) to develop mini prosthetic pancreases that are designed to withstand the patient’s immune system.
There are also flaws with the CIRM model, in that it unrealistically assumes that there will be a wide enough field of medical expertise for those allocating the grants and those receiving them to stand completely separate. The stem-cell sector in California is inescapably cosy and there have been accusations of conflicts of interest. It also fosters a culture in which groupthink and networking might influence funding decisions.
Unfortunately, for a Labour leader who has loaded so much on to reviling nasty, greedy American private companies, Corbyn cannot cite CIRM without admitting to how brilliant these companies can be. Clichés never make things easier or simpler, but once you get into the living politics of “saving our NHS,” Corbyn might yet promise some attractive disruption.