The Scandal of Access: An Interview with Zahra Hayat

Zahra Hayat

This episode of the Matrix Podcast features an interview with Zahra Hayat, Assistant Professor of Anthropology at the University of British Columbia. She obtained her PhD in Anthropology at UC Berkeley, and is also trained as a lawyer with a background in intellectual property.

Matrix Content Curator Julia Sizek spoke with Hayat about her research on pharmaceutical access in the global South, particularly in Pakistan, and the regimes of price and property on which such access is contingent.

Listen to the podcast below or on Google Podcasts or Apple Podcasts. A transcript of the interview is included below, lightly edited for length and content.

Q: Let’s get started with the overarching question of your research, which is the “scandal of access,” the way pharmaceuticals are easily accessed in the West but are inaccessible in the global South, and the preventable deaths that result from this lack of access. What does contemporary access to pharmaceuticals in Pakistan look like?

It’s best to start with what I’m trying to gesture at with the title of my dissertation, which is “The Scandal of Access.” The idea of “scandal” is something that emerged very organically during my fieldwork. A lot of my interlocutors would refer to various things vis-a-vis pharmaceuticals and people’s inability to access them through the language of scandal. 

Over time, I began to think of it as much more than just a figure of speech or something that people would say rhetorically, and think about how conceptualizing scandal might help us understand what is going on vis-a-vis access to medicines in Pakistan.

I’m trying to get at a couple of things with this idea of scandal. First of all, the overarching meta scandal that defines the stakes of my work is that of preventable deaths. With a population of 220 million people, Pakistan is the fifth-most populous country in the world. And people there have some of the highest incidences of diseases that are treatable, if not fully curable. In the so-called West, this includes hepatitis C and breast cancer. Pakistan has among the highest rates of breast cancer in South Asia. These are all diseases for which medicines exist. And yet, due to lack of these and many other far simpler, older medicines, Pakistanis are either suffering needlessly, or dying prematurely. 

A particular example that might illustrate this idea of scandal is not a curative substance, but a palliative substance: morphine. The idea of scandal really first hit home for me when I started hearing over and over again from the people I spoke to how people with late-stage cancer in Pakistan, for whom treatment is no longer a viable option, and who can only be given palliation at this point, simply do not have access to pain relief medication. It is almost impossible for hospitals to get either fentanyl or morphine, which is the basic standard of care for terminal cancer patients in the West. 

The reasons for that are very counterintuitive. Usually we think of drugs as being difficult to access because they are too expensive–or they are under patent, and generic manufacture is not allowed in the global South, which is something we see in India a lot. In the case of morphine, none of these barriers to access actually exist. Morphine has been in use for pain relief for 200 years. It’s not under patent anywhere. And it’s one of the cheapest medicines, even in the Pakistani scale of medicine pricing. And yet it’s almost impossible to get in hospitals. And there is a very complicated constellation of bureaucratic policies and agencies, which has to do with a phobia of drug addiction and of morphine percolating into the illicit realm, and therefore contributing to the problem of addiction, as it’s called, so that people who have cancer are not able to get it.

It’s things like this that I am trying to get at with the idea of scandal. There’s something egregious about the idea that you have illicit counterparts of morphine circulating on street corners, and doctors are forced to tell patients to go to the street, to use that figure of speech, and try to find morphine for their loved ones. It is this element of egregiousness, of outrage, of a violation of some norm of decency or ethics. When people talk about this, there is a sense that this should not be happening, this should be easily preventable. And yet, as I tried to show and as I’ve learned, it’s anything but easy. This is a bit of texture of what I’m trying to get at with the idea of scandal.

Q: If you have a loved one in a hospital and are trying to figure out how to get access to morphine for palliative care, what do those steps look like? What are the rules governing whether or not you have access to morphine?

That’s a great question. Some of the things I’m going to say will be specific to morphine, but many of them will not, and they will be representative of the larger pharmaceutical landscape. In fact, ironically, just two days ago, one of my interlocutors at the drug regulatory authority of Pakistan, which one can see as the counterpart of the USFDA, sent me an article from one of the leading national dailies talking about how patients with cancer, including children — and they were a large focus of the piece — are suffering horrifically, because of the pain of end-stage cancer, and how it’s just impossible to get morphine. Senior oncologists who were interviewed for that piece spoke about how the entire bureaucratic regime that governs controlled substances, of which morphine is one, is so complicated and lengthy that the companies that are trying to supply morphine sometimes have to wait months and months in order to get an approval for a quota of morphine.

I’ll give you a very specific example: there are one or two companies that are still supplying morphine in Pakistan. That in itself is scandalous. We have 220 million people, we have over 800 registered pharmaceutical companies, and only two of them are actually selling morphine. The reasons for this are twofold: one has to do with pricing, and one has to do with what I’m calling bureaucracy, just as a placeholder for now. 

I’ll talk about the bureaucracy piece. I spoke with the CEO of a company in detail, and she explained to me just how excruciating the process is for them. They import their morphine from Switzerland, because the technology that they need, modified or slow release, they’re not able to make locally. So it’s imported from Switzerland. Before they can put in an order for import, they have to apply for permission from the drug regulatory authority and a constellation of other bureaucratic agencies, including the anti-narcotics force. And this permission is not something that’s granted to them as a blanket permission. You get it once, and then they know that you’re supplying morphine, and that’s it. Every time they want to place an order for morphine, they have to secure this permission.

The biggest roadblock here is that, before they can submit an application for new stock, their existing stock has to finish. This seems like such a simple timing-related glitch to fix, but it has not been fixed for years and years, because it’s not just a simple bureaucratic glitch. And this is what I’m trying to get at, that these things do not have quick fixes. As this person explained to me, once they are down to zero for their quota of morphine, that’s when they’re able to submit an application. That application can take anywhere from three to six months to approve. Once it gets approved, you can place an order with your supplier in Switzerland, and there’s lead time for that order, as well. 

The consequence of this is that, for about six months of the year, this company has no morphine to supply to hospitals, and hospitals simply don’t have morphine. So what they end up doing with patients is either just turning them away or saying that they can go buy their own heroin, which is the illicit counterpart of morphine, derived from the same opium poppy plant. They tell them that you can try and go to one of “addas,” which is basically a figure of speech in Urdu, a trope for where drug addicts tend to huddle. That’s the trope, it’s a caricature. Go to those street corners, go to those drug addicts, try to get heroin from them.

This undertaking is impossible for a lot of people. Sometimes in desperation, they do this. They do go to addas and get morphine. But then they talk about how you don’t know what you’re getting, you absolutely have no sense of the purity or the quality of it. But at that point, the need is so dire that you’re not even thinking about questions such as, what is the quality of this material? Anything that will relieve the pain is what will do.

The bureaucratic control issue is specific to morphine and other controlled substances. This is not a Pakistan-specific problem. Across the global South, access to morphine is a huge issue. Julie Livingston’s work on cancer in Botswana mentions the same thing. And if you compare the statistics for consumption of morphine per capita in a country like the US and a country like Pakistan, the difference is literally thousands of percentage points different. And of course, advanced cancer is much more common in places like Pakistan because of late diagnosis. So the need and availability are just completely disjunct.

The second piece that I want to talk about has to do with price. And this is a much broader problem that has a very central connection to the problem of access in Pakistan. That has to do with state regulation of pricing. The drug regulatory authority of Pakistan sets the maximum retail price for every drug that can be sold in the country. And these price ceilings that they set are unviably low for a lot of corporations. This is not just something the corporations are saying to me, that I’m taking them at their word. This is actually from having looked at their detailed cost data. A lot of my fieldwork was in these pricing meetings of the drug regulatory authority, which was access that I was very lucky to get, and to actually see that a lot of these companies are supplying products at a loss. And morphine was one of them.

Why the drug regulatory authority is so hesitant to grant price increases has very fraught political reasons. The disincentive for companies to supply medicines is that you’re not going to be making much of a profit. This doesn’t apply to all drugs, but specifically to morphine and to many other simple, cheap drugs.Given that it’s so complicated to get these approvals and quotas, most companies simply don’t want to get into this. The CEO of one company that still provides morphine on a humanitarian basis, in their words, because it’s making a loss for them, said that you’d have to be crazy to get into this business.

Especially in the US, people think about access to pharmaceuticals being limited by ability to pay. We hear conversations about the price of insulin, for example, which is about people being priced out of buying drugs they need. But what you’re describing here is actually a case where low prices are prohibiting access. Can you explain how that works?

This was perhaps the biggest surprise of my fieldwork. I actually had no idea about this before I started fieldwork and then literally every person that I met in the pharmaceutical industry would begin our conversation by talking about the problem of prices being too low, and that being the reason for so many drugs not being available on the market. So it is a very counterintuitive kind of relationship between price and access.

I just want to add a caveat and say that there are drugs that are in fact, in absolute terms, too expensive for most people in Pakistan to afford. And these especially include anti-cancer drugs. However, from the point of view of pharmaceutical companies, the price ceiling that is set for most drugs is unviable. That, of course, is a subjective term. For some, the complaint is that the profit that they’re making is simply too low to continue supplying this drug. For some, as in the case of morphine, they might actually be supplying the drug at a loss.

So why is this happening? What is this rigid regime of price controls that is actually pushing a lot of drugs out of the market? Take the example of something as simple as a thyroid drug, levothyroxine synthroid. It’s one of the most commonly prescribed drugs in the US. In Pakistan, it is actually out of stock at pharmacies. And one of the reasons is that it’s an extremely cheap drug. It costs a few rupees. And as soon as it hits the market, a lot of it gets bought up by middlemen, as they are called, and diverted to black markets, or gray markets, as a lot of my interlocutors refer to them. They will either be taken out of Pakistan, sometimes at a small scale, on a flight in somebody’s personal luggage, or they will be sold on the “black market.”

The regulatory authority under federal law, the drugs act, is authorized to set the price of every medicine in the country. The rationale for setting the prices that they do is that this is a country with a very poor and very sick population. And in order to give them access to medicines, we have to keep the prices low. The logic is that the free market cannot be allowed to run amok in a country like this. That logic is theoretically sound, because we have seen what happens when the “free market” takes over, resulting in astronomical drug prices, as in the US, where the government is really constrained because of the pharmaceutical lobby from controlling or lowering drug prices. But in Pakistan, what seems to have happened is that this has been taken too far, in some cases. And there is so much rigidity, even over the granting of a small price increase that might make a product viable for a pharma company, that companies sometimes simply do not want to deal with the hassle and the months and months of negotiation that they need to deal with the regulatory authorities, and they simply withdraw the drug from the market.

I want to say a couple of things about this, one from the point of view of the regulators, and the second from the point of view of the companies. With the regulatory authorities, once you really start probing, you find a lot of people who agree that this entire regime is fundamentally not working. They agree that drug price increases should be granted, but they operate under a lot of constraints. And the constraint comes from very unexpected sources that actually have nothing to do with the economics of supply and demand. One of the biggest sources of this constraint is political pressure. Medicines are a hot button issue in the country because of the large sick population, and it is something that the propagandist media likes to really home in on. Any time a price increase is granted by the regulatory authority — for instance, the price of a cheap medicine was raised from two rupees, which is some decimal points of a cent, to four rupees — it was presented as, “prices of many essential medications increased by 100 percent.” The national newspapers will carry that news.

These price increases are recommended by the regulators, and then they have to go to the legislature for approval. I’ve been told by official after official that the legislators will simply not sign off on the price increase, because they’re scared of bad publicity from being the people who approved the price increase. So we’re dealing again with a very complex constellation of democratic politics in a country that’s also controlled to a very large extent by the military, but where a propagandist media does have a lot of power to scare people.

The second piece that relates directly to scandal is a history of an anti-corruption agency in the country called the National Accountability Bureau, which is a very activist government department. It is controlled by the military, to an extent that many people think of it as an instrument of political scapegoating. There was an actual scandal several years ago when price increases were granted to pharmaceutical companies, but then a NAB investigation was launched against those companies and many officials on the grounds that they must have accepted bribes from these companies in order to grant them the price increase. That history really reverberates among regulatory officials even today, and acts as a huge constraint. So there is just a lot of fear among those responsible for granting price increases to actually go ahead and grant them. This again is one piece of a very complex set of issues. But to me, this was all completely new, and made me realize that demand and supply and economics do not have very much to do with what’s going on with pricing in Pakistan.

Q: Your research also focuses on the intellectual property (IP) regime. Let’s dive into that. If you’re an American company, and you have made a drug, how does a Pakistani company get the ability to process that same drug under intellectual property law?

To set the stage, the Agreement on Trade-Related Aspects of Intellectual Property Rights, or TRIPS, is the instrument of the World Trade Organization that governs intellectual property across most of the world. The purported aim of this is to “harmonize” intellectual property laws among all signatory states. Now, there is obviously a very robust body of work that is critical of TRIPS and challenges this euphemism of “harmonization” as basically being an instrument of neoliberal control, because a lot of pharmaceutical “innovation,” a lot of new drugs or cutting-edge drugs, or especially biologicals, are being developed in the West, because of the huge resources required for R&D and clinical trials and so on. What these companies really want is not just to make profits in the global South, but also to control markets in the global South.

Here I want to point to something that’s fundamentally important to understand about how intellectual property works, which I can do through the example of a series of very high-profile patent battles that have taken place in India, for instance. And this is relevant for the case of Pakistan, as well. One of the most well known cases was of Novartis’s leukemia drug, GLEEVEC, which Novartis had a patent for abroad, and it was trying to get a patent in India. One of the most important things to know about TRIPS is that you need to apply separately in every country for a patent. Novartis went into India and tried to assert its patent. A lot of companies that were already making generic versions of GLEEVEC and selling them for thousands of dollars less and making this life-saving cancer drug accessible to a very poor Indian population, opposed the application for a patent, as did many nonprofits and patient advocate groups. Novartis really fought hard. There are scholars like Kaushik Sunder Rajan who have done very meticulous work on this precise case. What’s really interesting and revelatory about how intellectual property works is that Novartis was not trying to get the generics companies to stop making copies, as they call them, because they wanted to be the suppliers to the Indian population instead, and thus make a profit. And the reason for this is that even the lowest price that Novartis would be able to charge for GLEEVEC in India, would be something that most Indians would not be able to pay. While it was fighting this case, Novartis was also giving away a lot of GLEEVEC for free. What it said, as part of its litigation and the public relations fiasco that was happening around this case, was that if a patent is not upheld in India, they would withdraw this free GLEEVEC program that they had in place.

Scholars have really asked this question, why is Novartis so insistent on protecting its intellectual property, even when it is not making a profit on this drug and cannot make a profit on this drug? There are two reasons for this, and I think they’re really important to understand, because they really tell us how IP now, especially in the pharma realm, works in the global South.

One reason is that a lowering of the price, which would be represented by a generic manufacturer, would stir up (and has stirred up) criticism among Novartis’s consumers in America and Europe as to why they are being charged astronomically high prices, when people in India can get the drug for a few thousand rupees. So there’s the possibility of arbitrage, of the drug being smuggled into the West. But apart from this concrete possibility, there are also the optics of a drug that people in the West are really struggling to be able to afford being available so cheaply. So it is to protect its international scaffolding of prices that Novartis would deprive Indian patients of the drug, even though it’s not going to make a profit there.

A second very important reason is how pharma companies use intellectual property not just to make profit in that particular country, but as a means of controlling certain markets. Here, again, the Indian example is very instructive because it contrasts radically with that of Pakistan. India is the world’s largest generics manufacturer, as we know. And so what Novartis and a lot of other pharmaceutical multinationals fear is that if generic versions of their drugs are made in India, they will then be exported, because these Indian companies are large exporters to markets, especially in Latin America, which these companies are very interested in making profits in. So what they’re trying to do by preventing generics manufacturers in India is not so much preserve their monopoly in India, and be able to sell to Indian patients, but to preserve their monopoly in other markets.

So we see how, even though normative law says that patents are only national in scope, it works as part of this vague, tangled, global web, which has repercussions for patients in the global South. And Pakistan very quickly falls into this calculus.

The clearest way to articulate this is that Pakistan does not matter to most pharmaceutical companies, and many of my interlocutors have told me in very evocative language that Pakistan is a decimal point correction in the profits of pharmaceutical multinationals, or the only value Pakistan has for pharma multi-national corporations is its nuisance value. What they’re trying to get at is the poverty of the Pakistani population and their inability to afford many of these drugs. But a crucial difference between a place like Pakistan and India is that big pharma also isn’t particularly interested in preventing generics manufacturers in Pakistan because Pakistani companies are not big exporters at all. So it’s not like big pharma’s other markets are under threat from Pakistan. So what ends up happening is that, when a new drug is developed in, say, the US or Switzerland, it will in most cases simply not make its way to Pakistan at all. So the pharmaceutical company is not going to go in or even bother applying for a patent on the drug, because it knows that it doesn’t really have anything to gain, either from selling in this market, or from preventing generics manufacture in this market.

Countries like Pakistan tend to get bypassed, and so we end up in this paradoxical situation, where it’s not actually patents on these new drugs that are preventing the population’s access, but rather it’s that the companies are not even motivated to apply for patents in the country. And so what we have in the case of Pakistan is very different from the more standard Big Pharma versus local generics standoff, which has been extensively researched and written about, with India being one of the main sites for this because of its generics industry. Places like Pakistan are left out of that narrative, and of these particular flows of global pharmaceuticals capital, by just not mattering enough.

Q: It’s both enlightening and depressing to think about this intersection of these companies’ impulse to try to make more money with the idea that it’s just not worth it to apply to protect their intellectual property in a place like Pakistan. One of the interesting ways this shows up in your research relates to the case of Hepatitis C, which is quite prevalent in Pakistan. Can you tell us about that case specifically?

Absolutely. Hep C is a great example because the drug for Hep C, Sovaldi, is a very rare exception to the trend of the newest Western drugs not coming to Pakistan.

First of all, the incidence of Hep C in Pakistan is extremely high. Unofficial figures have it as high as 10%, but it could be higher. Before 2015, the treatment for Hep C was the way you would treat a chronic disease that you couldn’t really cure. There were interferon injections. It was an exhausting, long, and very expensive process. And there was a lot of suffering in Pakistan because of hepatitis C.

The spread of Hepatitis C is something that the narrative in the global health landscape tends to focus on, particularly with the population in the global South. And there’s obviously a critique of that, because it is, I think, redirection of focus from big pharmaceutical capital and how it works to sort of patient behavior, you know, and we have obviously seen a trend in anthropology and medical anthropology from directing our attention elsewhere to these larger structures of exploitation and inequality, instead of just talking about how patients or how people have issues with hygiene or compliance and so on.

That said, as part of this landscape, there is a lot of sharing of syringes among drug users, and there aren’t any safety protocols in place for them. There tends to be a demographic where Hep C is very high. But there’s an actual fear among people in Pakistan of contracting hepatitis C if you go to a dentist, or if you go and have your hair cut. These are legitimate fears, because there have been instances of many people contracting Hep C in these ways, it is so prevalent in the population, and it can remain latent for a while. The chances of getting infected are actually very high. If I’m not mistaken, Pakistan actually has the highest rate of hep C in the world, Egypt used to be at the top, but Egypt has largely eradicated the disease.

That brings me to the story of Sovaldi, which is a drug that was hailed by everybody as a paradigm-shifting drug brought to market by Gilead, based here in Foster City, California. And it was considered such a transformative drug that it changed Hep C from a chronic condition to a completely curable condition, with a course of four weeks of taking a pill a day, as part of a combination of therapies. With Sovaldi, this shift from chronic management to cure happened very definitively and continues to be the case.

It came out in around 2016, and the FDA actually granted expedited review, as it does for really breakthrough therapies that are in urgent need. And it came to the US market. And really, it created a PR storm, in part because of the revolutionary nature of the drug, but also because of the staggering price tag that the drug came with. And this is something that has become etched in people’s minds, anybody who’s in the pharmaceutical world, that the price of a course of Sovaldi was $84,000. When you look at how structures of payment work in America, it’s not that the final patient would be paying this money out of pocket, but somebody would have to pay it. So insurers were hesitant to even authorize this drug. The $84,000 price tag, and the sticker shock that came with it, stirred a lot of conversation in the US about drug prices getting out of control.

If you look at the public filings of Gilead, and you look at some of the information about how they actually set this price, which they have to make public, because there was actually a congressional inquiry into how the price of Sovaldi was set in the US, you get this insight into how pharmaceutical companies think about pricing, and how radically different this is from the case of Pakistan. You’re not thinking about what the government will allow, what can we get away with without inciting an uproar, it’s literally couched in language like that. So they price it, it incited an uproar to an extent, but the company also made huge profits.

This is where I think Gilead also deserves credit. And I am trying not to write this as a simple black and white, “Big Pharma is evil, or Big Pharma is sort of this beneficent force in the world” kind of binary, because it’s obviously much more complicated than that. The case of Gilead really illustrates that, because while making these astronomical profits in America and Europe, Gilead started what is called the Gilead Access Program. It took Sovaldi to countries like Egypt and Pakistan, which had very high incidences of the disease and which could not pay even 1/100th of the price that Gilead was charging abroad. In Pakistan, Gilead, entered into a collaboration with a very well-reputed and respected Pakistani company called Ferozsons Laboratories. And they developed a strong working relationship over the years. This local company agreed to sell Sovaldi in Pakistan at two percent of the price that they were charging in the US. They were not going to make a profit with this price in Pakistan, but they were still breaking even, which gives you a sense of their profit margin in the US at the prices that they were charging.

The reason they wanted to do this sort of break-even strategy, and they way they pitch their Global Access Program is, this is not corporate social responsibility, this is not philanthropy, what we want is for a sustainable model, whereby drugs can make their way to people who need them the most and can’t pay for them in a way that the company can also sustain. There is good sense to that logic. And so this drug comes to Pakistan priced at two percent of its US price. It cost around 55,000 Rupees for a course, which is a little less than $500 (at the exchange rate at the time), which is still unaffordable for the large majority of people, but still much more than what the original price was.

The really interesting thing that happened has to do with intellectual property. Gilead then entered into a license with its local partner, Ferozsons, and gave Ferozsons permission to make a copy of Sovaldi. Locally, they gave them the technical know-how. And they basically helped them manufacture this copy, which was much more affordable. And as part of this license, there were certain stipulations that Ferozsons had to buy the raw material from companies that Gilead had approved. And some of these approved companies were in India. So Ferozsons was able to source the raw material from there and make much more affordable versions and start selling them in Pakistan.

Then something really interesting happened. Once local pharmaceutical companies caught on — they had already been on top of all of this, they knew that somebody had come out in America, they knew that something huge had happened — they all wanted to jump on the bandwagon. And they applied to the drug regulatory authority of Pakistan for registration, and said, we want to make copies. And the drug regulatory authority granted this registration to about 15 or so local companies. What this did was that the price of a course of Hep C medicine dropped down to something like a few thousand rupees.

In all of this, Gilead had an option. Gilead could have prevented this. But what did they need to do to prevent this? First, they needed to apply for a patent on Sovaldi in Pakistan. If they were granted that patent, they would then have to go to court and assert that patent right, and say that all of these local companies that don’t have a license with us are just making unauthorized copies, and this is a violation of our intellectual property. And the only company that shouldn’t be allowed is the company that we are actually partnering with, i.e. Ferozsons Laboratories. But Gilead did not do this.

The next point is really crucial to appreciate because what a lot of people say is that Gilead chose to relinquish its intellectual property and give this drug for free to people in Pakistan. Now, that’s partially correct, and Gilead didn’t actually have to do this. They could simply have sidestepped Pakistan altogether. But another way that we can think of this relinquishment of Gilead’s intellectual property is, what incentive does Gilead have to apply for a patent in Pakistan, and to follow it through?

Interestingly, I dug around a little bit and found that there was actually an application that was filed, but it was never really followed up. And when you speak with people at Gilead, they have conflicting stories of why they didn’t apply for a patent in Pakistan. But the upshot of all those stories is that it wasn’t in their interest to apply for a patent in Pakistan. There was no way that they could make a profit on Sovaldi in Pakistan. They couldn’t charge a price high enough to enable them to do that. And they don’t really see any Pakistani company as a threat to them. So this one company that they entered the license with, Ferozsons, is actually constrained from exporting the local version that it’s making. But Ferozsons really values their relationship with Gilead, and it is a very important relationship. So they wouldn’t really go against Gilead and try to flout their authority and try to compete with them anyway.

So in a way, Gilead is accomplishing the sort of control it wanted by having this license with the one company that it considers high quality. And it is bothered by this plethora of local copies. There is a lot of criticism coming from that end about how we don’t have any idea of the quality of these drugs because we have no control. We don’t know where they’re sourcing their API (Active Pharmaceutical Ingredient) and so on. But again, they’re not pushed enough to stop any of this, because it’s not really affecting their profit.

What this case really illustrates is how intellectual property can bypass certain places. A relinquishment of intellectual property can be seen as an act of great largess. But it can also be seen as a very pragmatic calculation in capitalist, profit-driven logics. And I think that holding space for both of these is important. It would be wonderful if more companies did what Gilead did, because Sovaldi is one of the very rare instances of a brand new drug that is just released in the West coming to Pakistan within a year. This rarely happens. So far, nobody has really jumped on this bandwagon and tried to do this with another drug. But the hope is that this continues to happen. But I think while we laud these efforts, and why we try to have more of this, it’s just also important to be perhaps clear on the intellectual property dynamics and what is really at play.

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