Poor countries struggled to get covid vaccines. Now it’s happening with game-changing pills.

Licensing deals for low-income countries require factories to retool, and middle-income countries are left to compete with rich nations.

Poor countries are struggling to obtain new antiviral pills to treat covid, despite drugmakers’ promises to ensure wide access — in an uncomfortable echo of the global divide on covid vaccines.

Pfizer’s Paxlovid and Merck’s molnupiravir are the first covid treatments designed to be taken at home. Both drugmakers have entered into licensing deals with the Medicines Patent Pool (MPP), a U.N.-backed public health organization that works to make medicine accessible for low- and middle-income countries. Merck has also licensed its pill directly to several generic drug manufacturers in India.

“We are seeing the same pattern of hoarding, fighting, as we already saw with vaccines for the past three years,” said Yuanqiong Hu, a senior legal and policy adviser at Doctors Without Borders’ Access Campaign. “Limited supply has been pre-booked by who has money and who is quicker.”

Unequal access to vaccines has made it harder for low- and middle-income countries to prevent new covid cases. Any barriers to accessing the new antiviral pills could also put these countries at a disadvantage treating the sick. That’s not just a blow to people who live in these countries. As long as there are places where the virus is spreading rapidly, the world faces the risk that new and damaging variants will emerge.

Middle-income countries get creative

Public health experts predict the European Union and rich countries will soon buy up the rest of Pfizer’s 2022 supply.

“We let rich countries have preferential access through political power, economic power and willingness to pay higher prices,” said Brook Baker, a law professor at Northeastern University who studies access to medicine. “We’ve gotten exactly what you would predict. If a company has a monopoly, it can limit supply, it can set high prices.”

But although most countries can issue compulsory licenses that allow third parties to produce a patented drug without the permission of the patent holder, they often try to avoid doing so out of fear of retaliation from trading partners.

If a government does not act on its own, outside entities can step in — depending on that country’s patent rules — and ask the government to take action.

“No company is going to be able to supply a global market to address the problems of covid-19, neither in the case of vaccines, nor in case of treatments,” said Luis Gil Abinader, a senior researcher at KEI who is leading the group’s licensing efforts in the Dominican Republic, his home country. “It is mandatory, if we want to end the pandemic as quickly as possible, to share the intellectual property and to share the know-how.”

KEI’s filing in the Dominican Republic was the first attempt in any country to establish a compulsory license for Paxlovid. If the group succeeds, Gil Abinader anticipates this will jump start such efforts in other nations. “If the Dominican Republic breaks the compulsory license taboo on licensing, we think other countries will do the same,” he said.

Prices will vary

If Pfizer opposes KEI’s request, the government of the Dominican Republic could make a decision on the license in court, Gil Abinader said. The drug company, which told Grid it does not believe compulsory licenses are necessary, has asked the government for more time to submit a reply. Once Pfizer files, KEI can request a hearing. That could happen as soon as April.

“We do not believe that granting compulsory licenses to PAXLOVID is an appropriate or constructive approach to improving access,” Pfizer spokesperson Sharon J. Castillo said in an email to Grid. “We are committed to working directly with governments and other stakeholders to ensure that our medicine is accessible and affordable for those who need it.”

Pfizer has said it will use a tiered pricing model with Paxlovid, adjusting its price based on a country’s income. Rich countries will pay higher prices than middle- or low-income nations. That does not guarantee that nations will be able to afford the drugs in sufficient quantity to treat their populations, however.

“We’ve already been seeing this for 20 years in HIV, where you segment the market according to economic level and try to maximize the profit you can get out of any given country or region,” said Rachel Cohen, the North American regional executive director for the nonprofit Drugs for Neglected Diseases Initiative. “This is one of the limitations of the voluntary approach that allows [the] industry to call the shots and dictate the terms of these agreements rather than having the goal be maximizing production capacity to meet global needs.”

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