The political economy of Ebola

The Onion, as ever, is on point with its “coverage” of the worst recorded outbreak of Ebola, and the first in West Africa, infecting some 1,779 people and killing at least 961. “Experts: Ebola Vaccine At Least 50 White People Away,” read the cheeky headline of the July 31 news brief.

Our shorthand explanation is that if the people infected with Ebola were white, the problem would be solved. But the market’s role in both drug companies’ refusal to invest in research and the conditions on the ground created by neoliberal policies that exacerbate and even encourage outbreaks goes unmentioned.

Racism is certainly a factor. Jeremy Farrar, an infectious disease specialist and the head of the Wellcome Trust, one of the largest medical research charities in the world, told the Toronto Star: “Imagine if you take a region of Canada, America, Europe, and you had 450 people dying of a viral hemorrhagic fever. It would just be unacceptable — and it’s unacceptable in West Africa.”

He noted how an experimental Canadian-developed Ebola vaccine had been provided on an emergency use basis to a German researcher in 2009 after a lab accident. “We moved heaven and earth to help a German lab technician. Why is it different because this is West Africa?”

But Ebola is a problem that is not being solved because there is almost no money to be made in solving it. It’s an unprofitable disease.

There have been around 2,400 people killed since Ebola was first identified in 1976. Major pharmaceutical companies know that the market for fighting Ebola is minute while the costs of developing treatment remain significant. On a purely quantitative basis, some might (perhaps rightly) warn against focusing too much on this one disease that kills far fewer than, for example, malaria (300,000 killed since the start of the Ebola outbreak) or tuberculosis (600,000).

Yet the economic constraints retarding progress in developing Ebola treatment also explain why drug companies are resisting developing treatment to those diseases as well as many others.

The last decade has actually seen a tremendous advance in research into therapies for Ebola, usually in the public sector or by small biotech companies with significant public funding, with a variety of treatment options on the table including nucleic-acid-based products, antibody therapies, and a number of candidate vaccines — five of which have successfully protected non-human primates from Ebola.

Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, has been telling everyone in the press who will listen to him in the last fortnight that an Ebola vaccine would be within spitting distance — if it weren’t for the corporate skinflints.

“We have been working on our own Ebola vaccine, but we never could get any buy-in from the companies,” he told USA Today.

“We have a candidate, we put it in monkeys and it looks good, but the incentive on the part of the pharmaceutical companies to develop a vaccine that treats little outbreaks every thirty or forty years — well, that’s not much incentive,” he told Scientific American.

Almost everyone familiar with the subject says that the know-how is there. It’s just that outbreaks are so rare and affect too few people for it to make development worthwhile — that is, profitable — for large pharmaceutical companies.

“These outbreaks affect the poorest communities on the planet. Although they do create incredible upheaval, they are relatively rare events,” Daniel Bausch, the director of the emerging infections department of Naval Medical Research Unit Six (NAMRU-6), a biomedical research laboratory in Lima, Peru, told Vox. “So if you look at the interest of pharmaceutical companies, there is not huge enthusiasm to take an Ebola drug through phase one, two, and three of a trial and make an Ebola vaccine that maybe a few tens of thousands or hundreds of thousands of people will use.”

John Ashton, president of the UK Faculty of Public Health, wrote a vituperative opinion piece in the Independent on Sunday decrying “the scandal of the unwillingness of the pharmaceutical industry to invest in research to produce treatments and vaccines, something they refuse to do because the numbers involved are, in their terms, so small and don’t justify the investment.

“This is the moral bankruptcy of capitalism acting in the absence of an ethical and social framework,” he concluded.

This situation is not unique to Ebola. For thirty years, the large pharmaceutical companies have refused to engage in research into new classes of antibiotics. Due to this “discovery void,” clinicians expect that within twenty years, we will have completely run out of effective drugs against routine infections. So many medical techniques and interventions introduced since the 1940s depend upon a foundation of antimicrobial protection. The gains in life expectancy that humanity has experienced over this time depended on many things, but would certainly not have been possible without antibiotics. Prior to their development, bacterial infections were one of the most common causes of death.

In April, the World Health Organization issued its first-ever reporttracking antimicrobial resistance worldwide, finding “alarming levels” of bacterial resistance. “This serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country,” the UN health body warned.

The reason for this is straightforward, as the companies themselves themselves admit: It simply makes no sense to pharmaceutical companies to invest an estimated $870 million (or $1.8 billion accounting for the cost of capital) per drug approved by regulators on a product that people only use a handful of times in their life when suffering from an infection, compared to investing the same amount on the development of highly profitable drugs for chronic diseases such as diabetes or cancer that patients have to take every day, often for the rest of their lives.

Every year in the US, according to the CDC, some two million people are infected with antibiotic-resistant bacteria. 23,000 die as a result.

We see an identical situation with vaccine development. People purchase asthma drugs or insulin, for example, for decades, while vaccinations usually require only one or two doses once in a lifetime. For decades now, so many pharmaceutical companies have abandoned not just vaccine research and development but production as well, that by 2003, the US began to experience shortages of most childhood vaccines. The situation is so dire that the CDC maintains a public website tracking current vaccine shortages and delays.

But at least with respect to Ebola, where the market refuses to provide, the defense department is comfortable intervening and setting aside free-market principles in the interests of national security.

Virologist Thomas Geisbert of the University of Texas Medical Branch at Galveston told Scientific American about his hope for the VSV vaccine, one of the most promising options against Ebola:

We’re trying to get the funds to do the human studies … but it really depends on financial support for the small companies that develop these vaccines. Human studies are expensive and require a lot of government dollars. With Ebola, there’s a small global market — there’s not a big incentive for a large pharmaceutical company to make an Ebola vaccine, so it’s going to require government funding.

William Sheridan, the medical director of BioCryst Pharmaceuticals, the developer of experimental anti-viral drug BCX4430, describes the financial predicament facing Ebola treatment research and development: “It just wouldn’t make the cut at a major company.”

But for a small company like his, the federal government has both backed research and promised to purchase stockpiles of anti-Ebola drugs as a preventative measure against bioterrorism. BCX4430 is also co-developed with the US Army Medical Research Institute for Infectious Diseases (USAMRIID). “There is a market, and the market is the US government,” he told NPR.

USAMRIID, along with Canada’s Public Health Agency, is also backing the development of ZMAPP, a serum of monoclonal antibiodies by a small San Diego-based biotech firm MAPP Biopharmaceutical, which was administered last week to two American doctors, Kent Brantly and Nancy Writebol, working with the evangelical Christian missionary group Samaritan’s Purse.

The pair had fallen ill in Liberia while taking care of patients infected with Ebola. Brantley’s condition had been rapidly deteriorating, and he had phoned his wife to give his farewells. Within an hour of Brantley receiving the experimental serum, his condition had reportedly reversed, with his breathing improving and rashes fading.

The following morning, he was able to shower on his own, and by the time of his arrival in the US after being evacuated from Liberia, he was able to climb down out of the ambulance without assistance. Writebol is now similarly “up and walking,” after her arrival in Atlanta from the Liberian capital.

We should be extremely cautious about drawing any conclusions from this development and claiming that the drug has cured the missionaries. We have a sample size of just two in this “clinical trial,” with no blinding or control groups. The drug had until now never been tested on humans for safety or efficacy. And as with any illness, a certain percentage of patients will recover on their own. We do not know whether ZMapp was the cause of the apparent recovery. Nonetheless, it is not unreasonable to state that this turn of events gives great hope.

Two of the ZMapp antibodies were originally identified and developed by researchers at the National Microbiology Laboratory in Winnipeg and at Defyrus, a Toronto-based “life sciences biodefense company,” with funding from the Canadian Safety and Security Program of Defence R&D Canada. The third antibody in the cocktail was produced by MappBio in collaboration with USAMRIID, the National Institutes of Health, and the Defense Threat Reduction Agency. The companies then partnered with Kentucky Bioprocessing in Owensboro, a protein production company that was bought earlier this year by the parent firm of RJ Reynolds Tobacco, to pharm the antibody-laden tobacco plants.

On hearing of the role of the Pentagon and Canada’s defense establishment, some have jumped to conspiracy theories. Indeed, ZMapp appears to be a perfect storm of popular nemeses: GMOs, Big Tobacco, the Pentagon, and injections that look a bit like vaccines!

But the Defense Department funding should not be viewed as nefarious. Rather, it is evidence of the superiority of the public sector as shepherd and driver of innovation.

However, not all unprofitable diseases are subjects of the colonels’ bioterror concern. And why should the private sector get to cherry pick the profitable conditions and leave the unprofitable ones for the public sector?

If, due to its profit-seeking imperative, the pharmaceutical industry is structurally incapable of producing those products that are required by society, and the public sector (in this case in the guise of the military) consistently has to fill in the gaps left by this market failure, then this sector should be nationalized, permitting the revenues from profitable treatments to subsidize the research, development, and production of unprofitable treatments.

In such a situation, we would no longer have to even argue whether the prevention of malaria, measles, or polio deserves greater priority; we could target both the big name and neglected diseases at the same time. There is no guarantee that turning on the tap of public funding will immediately produce a successful result, but at the moment, private pharmaceutical companies aren’t even trying.

This is precisely what is meant when socialists talk of capitalism being a fetter on the further development of the forces of production. Our concern here is not merely that the refusal of Big Pharma to engage in neglected tropical disease, vaccine, and antibiotic R&D is grotesquely immoral or unjust, but that the production of a potential cornucopia of new goods and services that could otherwise benefit our species and expand the realm of human freedom are blocked due to the free market’s lethargy and paucity of ambition.

Focusing on a vaccine or drugs is critical. But doing so without also paying attention to the deterioration of public health and general infrastructure across West Africa, and the wider economic conditions that contribute to the likelihood of outbreaks of zoonotic diseases like Ebola, is at best using a bucket to empty the water out of a leaky and sinking boat.

Phylogeographer and ecologist Rob Wallace has described well how neoliberal fallout has established the ideal conditions for the epidemic. Guinea, Liberia, and Sierra Leone are some of the poorest countries on the planet, ranking 178th, 174th, and 177th out of 187 countries in the UN’s Human Development Index.

Were such an outbreak to occur in northern European countries, for example, nations with some of the best health infrastructure in the world, the situation would more likely have been contained.

It is not merely the dearth of field hospitals, lack of appropriate hygiene practices in existing hospitals, absence of standard isolation units, and limited cadre of highly trained health professionals that are able to track down every person that may have been exposed and isolate them. Or that better supportive care is a crucial condition of better outcomes, whatever the treatment available. The spread of the disease has also been exacerbated by a withering away of basic governmental structures that would otherwise be able to more broadly restrict movement, to manage logistical difficulties, and to coordinate with other governments.

Epidemiologist and infectious diseases specialist Daniel Bausch, who worked on research assignments near the epicenter of the current outbreak, describes in a paper published in July in the Public Library of Science journal Neglected Tropical Diseases how he “witnessed this ‘de-development’ firsthand; on every trip back to Guinea, on every long drive from Conakry to the forest region, the infrastructure seemed to be further deteriorated — the once-paved road was worse, the public services less, the prices higher, the forest thinner.”

Wallace notes that here, as in many countries, a series of structural adjustment programs have been encouraged and enforced by Western governments and international financial institutions that require privatization and contraction of government services, removal of tariffs while Northern agribusiness remains subsidized, and an orientation toward crops for export at the expense of food self-sufficiency. All of this drives poverty and hunger, and, in turn, competition between food and export crops for capital, land, and agricultural inputs leads to an ever greater consolidation of land ownership, in particular by foreign companies, that limits access of small farmers to land.

Ebola is a zoonotic disease, meaning a disease spread from animals to humans (or vice versa). Some 61 percent of human infectionsthroughout history have been zoonotic, from influenza to cholera to HIV.

The single biggest factor driving growth in new zoonotic pathogens is increased contact between humans and wildlife, often by the expansion of human activity into wilderness. As neoliberal structural adjustment forces people off the land but without accompanying urban employment opportunities, Wallace points out, they plunge “deeper into the forest to expand the geographic as well as species range of hunted game and to find wood to make charcoal and deeper into mines to extract minerals, enhancing their risk of exposure to Ebola virus and other zoonotic pathogens in these remote corners.”

As Bausch puts it: “Biological and ecological factors may drive emergence of the virus from the forest, but clearly the sociopolitical landscape dictates where it goes from there — an isolated case or two or a large and sustained outbreak.”

These outcomes are the predictable result of unplanned, haphazard development in areas known to be the origin of zoonotic spillover, and without the sort of infrastructural support and egalitarian ethos that permitted, for example, the elimination of malaria from the American South after World War II by the CDC in one of its earliest missions.

Over these past few months, the worst Ebola outbreak in history has exposed the moral bankruptcy of our pharmaceutical development model. The fight for public health care in the United States and the allied fight against healthcare privatization elsewhere in the West has only ever been half the battle. The goal of such campaigns can only truly be met when a new campaign is mounted: to rebuild the international pharmaceutical industry as a public sector service as well as address wider neoliberal policies that indirectly undermine public health.

We could take inspiration from HIV/AIDS activist groups from the late 80s/early 90s like ACT UP and the Treatment Action Group, and, in the 2000s, South Africa’s Treatment Action Campaign, which combined direct action and civil disobedience against both companies and politicians with a scientifically rigorous understanding of their condition.

But this time, we need a larger, more comprehensive campaign covering not just one disease, but the panoply of market failures with respect to vaccine development, the antibiotic discovery void, neglected tropical diseases, and all neglected diseases of poverty. We need a science-based treatment activism that has the long-term, ambitious but achievable aim of the pharmaceutical industry’s democratic conquest.

We need a campaign to destroy the unprofitable diseases.

(From the: Jacobin)