The Hepalogue

O Rose, Thou Art Sick

by The Golden Phaeton on 05/07/2016

Whispers diffuse like a cold breeze through the vaulted chambers and cobwebbed passages of The Citadel.

For many seasons, certain Maesters – aloof from their brothers – have wrestled with the meaning of a primaeval miasma which – even in that time ere the Doom came to Valyria – has stricken us with a Curse. These men wear a link of nucleated erbium in their maester-chains. It signifies a mastery of biotechnology.

Now change is afoot. So many who have come, scarcely able to will their withered bodies to our door, are leaving rejuvenated. It is said, truly I believe, that the Maesters in their delvings have exposed the essence of the miasma and bound it to their will.

Off the novel cures manufactured here of late, few have been properly trialled or prepared for market. Yet so astonishing are their effects that I question the sense in withholding them, even for a day.

I wonder also… that if the revered library of our institution was consumed by wildfire this moment… if all summonings and sacrifices, all alchemical provings, all desperate pleas to The Seven were to cease… then, among the many queer new serums and compounds filling the shelves of our apothecaries, might many more victims – perhaps all victims – of this Curse have a chance to find deliverance?

Almost, I think. The high-born certainly. Not so much the serfs…


New Hep C medications are appearing with surprising frequency; each one slightly more potent, or slightly more targeted than the last. The ongoing battle between the companies continues – for those last few percent towards a certain cure, for shorter treatment duration etc. – despite the back of the disease having already been broken.

When will it end? With a one-pill instant cure? A foolproof vaccine? Even if such marvels come to pass, I doubt if all those in need will have access.

Leaving Westeros (not for too long, I hope) you may recall that in a recent post I mentioned that AbbVie has been trialling a 12 week, two drug therapy which, in non-cirrhotic patients of all genotypes, seems to have a cure-rate nudging 100%.

This is extraordinary and heartening news by any standard, but last week it seems to have been eclipsed. AbbVie has apparently been beaten to the punch (again) by Gilead Sciences.

In the wake of its approval in Europe, The US Food and Drug Administration has given the go ahead for a new Gilead combination pill called Epclusa (containing the stalwart sofosbuvir plus a new drug velpatasvir (NS5A inhibitor)). It has comparable rates of cure to current treatments over twelve weeks and ribavirin is added to the regimen in moderate to severe cases of cirrhosis (i.e. decompensated cirrhosis). (Suggesting that Epclusa is a little more effective with cirrhotic patients in general.)

Its big selling point is that it will work with all Hep C variants. Gilead points out also that it may ‘eliminate the need for genotype testing, which can be a barrier to treatment in certain resource-constrained settings’.

Sorry, but… Gag! Are these the magical ‘resource constrained settings’ where people cannot afford genotype testing, but can afford the eye-watering price of the treatment itself?

In the bear-pit of US drug pricing it almost makes sense that Epclusa, containing 400mg sofosbuvir (at USD74,760) actually costs less than 400mg sofosbuvir alone (sold as Sovaldi at USD84,000).

Several reasons have been suggested for this discount.

It may be possible that Gilead has seen the error of its ways and is easing back on its shameless price-gouging, particularly in the wake of Merck’s low pricing of their new genotype 1 cocktail Zepatier. According to Bloomberg ‘politics and PR matter more now than they used to’ and ‘few know better than Gilead the extent to which drug pricing has been politicised and publicised’ – particularly after the excoriating criticism they were forced to endure when they first released Harvoni at USD1,000 a pill.

More believable is that Epclusa (remember: a pan-genotypic cure) is much cheaper than the sofosbuvir/daclatasvir cocktail currently used to treat genotype 3 – and is aimed at eroding the market share of BMS, the makers of daclatasvir (Daklinza).

Now, try this choice cut of bare-faced hypocrisy from John Milligan, the CEO of Gilead :

“Today’s approval represents a significant advance for patients with HCV genotypes 2 and 3, who previously required more complex and costly regimens.”

My great aunt Mabel! Who made them more costly in the first place?

Sure, Gilead make all kinds of quiet deals with governments, insurers and pharmacy chains. In 2014 ‘the average discount to list price was 22%’ and early last year, ‘the company estimated that the average discount in 2015 would be 46%’. I don’t know whether the latter came true, but the whole process seems somewhat sleazy to me and – even after significant discounts like these – Gilead’s prices may still be reasonably described as astronomical.

I know it’s kind of obvious, but there really is something deeply askew here. An absolute good – i.e. wonderful new life-saving drugs – is inextricably bound with exploitation and greed. You have to wonder… how did such complete opposites ever come to be bedfellows?

I’m no expert, but I think It comes down to the root elements of capitalism. Corporations are obliged to generate as large a return on their share-holders’ investments as possible. If there is insufficient return, then why on Earth should they bother saving people’s lives? It’s not their job.

But people do  like having their lives saved and will pay through the nose for it. And there lies the rub.

In a capitalist society there are no other mechanisms by which such drugs could be developed. Philanthropic trusts, perhaps… perhaps… and that’s more of a mechanism for rich bastards to assuage their guilt – and it relies on there being rich bastards in the first place. Then there’s government-funded research, but that’s more an element of socialism than capitalism…

For most of my life, Australian society has lived in uneasy balance between socialism and capitalism. When greed becomes too overt, its perpetrators are shamed. When socialism dominates, then incentives dissolve (at least for those for who wealth is an aim in itself). Its a weird co-existence of opposing systems.

This might seem strange, but it makes me think of how many local councils cut out the heart of roadside trees to ease the passing of electricity lines. A promenade of beautiful plane trees or elms is maintained, but sharply curtailed (mutilated, actually) at the point of intersection with an equally important but in many ways opposing system.

I don’t think this is too different a thing to the greedy drug companies and their life-saving wares.

It’s the ugliness at these coordinates where both systems are forced to co-exist, which reminds us that opposing forces are in play, and that sometimes most unsatisfactory solutions are found to accommodate them both…

What I can say for sure is that we’re very very lucky to live in a land where some sort of equity is maintained – unlike the US where capitalism has run riot and where I find it difficult to imagine how someone like me (or you?) would ever get access to the new Hep C treatments.

The Golden Phaeton



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