What it takes to crush a pandemic Johanna Benesty
My son was born in January 2020,
shortly before the lockdown in Paris.
He was never scared
of people wearing masks,
because that’s all he knows.
My three-year-old daughter knows
how to say “gel hydro-alcoolique.”
That’s the French word
for hydroalcoholic gel.
She actually pronounces it
better than I do.
But no one wants to be wearing a mask
or wash their hands
with hand sanitizer every 20 seconds.
We’re all desperately looking at R and D
to find us a solution: a vaccine.
It’s interesting that in our minds,
we keep thinking of the vaccine discovery
like it’s the Holy Grail.
But there are a couple of shortcuts here
that I’d like to unpack.
I’m not a doctor, I’m just a consultant.
My clients focus on health care –
biopharma companies, providers,
global health institutions –
and they’ve educated me.
We need to find the tools to fight COVID,
and we need to make them
accessible to all.
First, one single vaccine
will not get us out of this.
What we need is an arsenal of tools.
We need vaccines, we need therapeutics,
we need diagnostics
to make sure that we can prevent,
identify and treat COVID cases
in a variety of populations.
Second, it’s not just
about finding a tool.
What do you think will happen
when one of those clinical trials
demonstrates that the tool is effective?
Do you think we can all
run to the pharmacy next door,
we get the product,
we take off our masks
and we go back to French kissing?
No.
Finding an effective tool
is just one step in this big fight,
because there is a difference
between the existence of a product
and access to that product.
And now you’re thinking,
“Oh – she means other countries
will have to wait.”
Well, no, that’s not my point.
Not only others may have to wait,
but any of us may have to.
The humbling thing about COVID
is that because of its speed
and magnitude,
it’s exposing all of us
to the same challenges
and giving us a flavor
of challenges we’re not used to.
Remember when China got into lockdown?
Did you imagine that you
would be in the same situation
a few weeks after?
I certainly didn’t.
Let’s go to the theoretical moment
when we have a vaccine.
In this case, the next access challenge
will be supply.
The current estimate
of the global community
is that by the end of 2021 –
so that’s over a year after
the discovery of the vaccine –
we would have enough doses
to cover one to two billion
of the eight billion of us on the planet.
So who will have to wait?
How do you think about access
when supply is short?
Scenario number one:
we let the market forces play,
and those who can pay the highest price
or be the fastest to negotiate deals
will get access to the product first.
It’s not equitable at all,
but it’s a very likely scenario.
Scenario number two:
we could all agree,
based on public health rationale,
who gets the product first.
Let’s say we agree that
health care workers would get it first,
and then the elderly
and then the general population.
Now let me be a bit more provocative.
Scenario number three:
countries who have demonstrated
that they can manage the pandemic well
would get access to the product first.
It’s a little bit extrapolated,
but it’s not complete science fiction.
Years ago, when the supply of high-quality
second-line tuberculosis drug was scarce,
a special committee was established
to determine which countries
had health systems that were strong enough
to ensure that the products
would be distributed properly
and that patients would follow
their treatment plans properly.
Those select countries got access first.
Or, scenario number four:
we could decide on a random rule,
for instance, that people get
to be vaccinated on their birthday.
Now let me ask you this:
How does it feel to think of a future
where the vaccine exists,
but you would still have to wear a mask
and keep your kids home from school,
and you would not be able
to go to work the way you want
because you wouldn’t
have access to that product?
Every day that passed
would feel unacceptable, right?
But guess what?
There are many diseases for which
we have treatments and even cures,
and yet people keep being infected
and die every year.
Let’s take tuberculosis:
10 million people infected every year,
1.5 million people dying,
although we’ve had a cure for years.
And that’s just because
we haven’t completely figured out
some of the key access issues.
Equitable access is the right thing to do,
but beyond this humanitarian argument
that I hope we are more sensitive to
now that we’ve
experienced it in our flesh,
there is a health and an economic argument
to equitable access.
The health argument is that
as long as the virus is active somewhere,
we’re all at risk of reimported cases.
The economic argument is that
because of the interdependencies
in our economies,
no domestic economy can fully restart
if others are not picking up as well.
Think of the sectors
that rely on global mobility,
like aerospace or travel and tourism.
Think of the supply chains
that cut across the globe,
like textiles or automotive.
Think of the share of the economic growth
that is coming from emerging markets.
The reality is that we need all countries
to be able to crush the pandemic in sync.
So not only is equitable access
the right thing to do,
it is also the smart thing to do.
But how do we do that?
Let’s make sure we’re on the same page
in terms of what “access” means.
It would actually mean
that the product exists;
that it’s working sufficiently well;
that it’s been approved
by the local authorities;
that it is affordable;
but also that there is evidence
that it works in all the populations
that need it,
and that can include pregnant women
or immunodepressed people, or children;
that it can be distributed
in a variety of settings,
like hospitals or rural clinics,
or hot climate or cold climate;
and that we can produce it
at the right scale.
It’s a very long checklist, I know,
and in a non-crisis situation,
we would likely address these issues
one after the other in a sequential way,
which takes a lot of time.
So what do we do?
Access is far from being a new challenge,
and in the case of COVID,
I have to say, we’re seeing
extraordinary collaboration
of international organizations,
civil society, industry and others
to accelerate access:
working things in parallel,
speeding up regulatory processes,
engineering supply mechanisms,
securing procurement,
mobilizing resources, etc.
Yet we are likely to face a situation
where, for instance,
the vaccine would need to be
constantly stored at, let’s say,
minus 80 Celsius degrees;
or where the treatment
would need to be administered
by a highly specialized
health care worker;
or where the diagnostic
would need to be analyzed
by a sophisticated lab.
So what more can we do?
Pushing further the logic
that the global health community
has advocated for for years,
there is one additional thing
I can think of that might help.
There is a concept
in product development and manufacturing
that’s called “design to cost.”
The basic idea is that
the cost management conversation
happens at the same time
as the product being designed,
as opposed to the product
being designed first
and then reworked to bring the cost down.
It’s a simple method that helps ensure
that when cost has been identified
as a priority criteria for a product,
it’s made a target from day one.
Now, in the context of health and access,
I think there is untapped potential
in R and D to access,
the same way that
manufacturers design to cost.
This would mean that,
instead of developing a product
and then working to adapt it
to ensure equitable access later,
all of the items
on the checklist I mentioned
would be built into the R and D process
from the beginning,
and this would actually benefit us all.
Let’s take an example.
If we develop a product
with equitable access in mind,
we might be able to optimize
for scale-up faster.
In my experience, drug developers
often focus on finding a dose that works,
and only after do they optimize
the dosage or make adjustments.
Now imagine that we’re talking
of a candidate product
for which the active ingredient
is a scarce resource.
What if instead we focused
on developing a treatment
that uses the lowest possible amount
of that active ingredient?
It could help us produce more doses.
Let’s take another example.
If we develop a product
with equitable access in mind,
we might be able to optimize
for mass distribution faster.
In high-income countries,
we have strong health systems capacity.
We can always distribute
products the way we want.
So we often take for granted
that products can be stored
in temperature-controlled environments
or requires a highly skilled
health care worker for administration.
Of course,
temperature-controlled environments
and highly skilled health care workers
are not available everywhere.
If we were to approach R and D
with the constraints
of weaker health systems in mind,
we might get creative
and develop sooner, for instance,
temperature-agnostic products
or products that can be taken
as easily as a vitamin
or long-lasting formulations
instead of repeat doses.
If we were able to produce and develop
such simplified tools,
it would have the added benefit
of putting less strains
on hospitals and health systems
for both high- and low-income countries.
Given the speed of the virus
and the magnitude
of the consequences we’re facing,
I think we have to continue
challenging ourselves
to find the fastest way
to make products to fight COVID
and future pandemics accessible to all.
In my perspective,
unless the virus disappears,
there are two ways this story ends.
Either the scales tip one way –
only some of us get access to the product
and COVID remains a threat to all of us –
or we balance the scales,
we all get access to the right weapons,
and we all move on together.
Innovative R and D can’t beat COVID alone,
but innovative management
of R and D might help.
Thank you.