The Coronavirus pandemic raises many questions about public health, global diseases and the way we produce and distribute cures and treatments. Who pays for the corona vaccine and how? How is that innovation organised? Who profits?

Commons Network has been an advocate in this domain (‘access to medicines’) for years. In the next few months, we will publish a series of articles about the problems with the current system and the ideas and visions that exist to change this. Today, we discuss the proposal for a Covid-19 Knowledge Pool.

COVID-19 is a global health crisis that demands an immediate global response. But this crisis also lays bare many other crises in our societies. In many Western countries, the response to the virus has shown the vulnerabilities in our public health systems and other essential sectors of society. One major issue that the coronavirus exposes is the dire state of our biomedical system and the role that pharmaceutical companies play in that system.

• In The Netherlands, for instance, hospitals didn’t have enough test kits because Roche, the world’s largest biotech company, initially refused to hand over the recipe that is needed to perform these tests.
• In the United States, Trump’s ‘corona-minister’ Alex Azar released a statement saying that the government could not guarantee that a potential cure for Covid-19 would be affordable, because the innovation that is needed for that cure would only be spurred by high profits.
• The rush to create a vaccine was delayed for up to two or three years, because in most countries, pharmaceutical companies had sold their vaccine research facilities. And the companies that still had the capabilities to do the research had effectively scaled down their coronavirus research because there was no money to be made.
• Scientists were close to a coronavirus vaccine years ago, and then the money dried up.
• The vaccine market was even called ‘an oligopoly’ by Wall Street analysts at AB Bernstein. In fact, after countries abandoned infectious disease research, most companies also moved away from investing in this field, according to DNDi director Bernard Pecoul.
• In France, it was debated why a testing kit for coronavirus should cost 135 euro, eventhough the production costs are only 10 euros. The sub-optimal availability of tests was cited as a major reason for not testing in the fight against the pandemic in many European countries, leading many people to ask if this had economic reasons as well.

More and more people have now come to realise that the global race to find a cure for Covid-19 and a vaccine is slowed down considerably by the fact that the system we have now runs on market incentives and patent monopolies. Instead of shielding essential knowledge, companies could work together, share research results and new insights.

Moving away from a deficient system

The pharmaceutical industry is driven by profit and guided by shareholders. The research and innovation that is needed to come up with cures and treatments is monopolised. A system of patents and licenses is fine-tuned to produce the maximum wealth for a few multi-billion euro corporations. This is how we have organised the world of medicines today. Our system is not driven by public health needs but by profit and the only logic that counts is that of capitalism.

Our system is not driven by public health needs but by profit and the only logic that counts is that of capitalism

This model is based on the belief that the flow of biomedical knowledge should be privatized and protected through intellectual property rights in order to stimulate innovation. This monopoly model gives pharmaceutical companies the freedom to charge as much as they can get away with. It also stifles innovation where we most need it, like in the area of infectious diseases, because there is no money to be made. And finally, this system makes us, the people, pay three times: once to fund the universities and research facilities that create a lot of the knowledge needed for pharmaceutical innovation, once to pay these companies to produce and distribute, and once to our governments to fund our health care system.

It’s hard to estimate how many medicines are not invented, how much talent is wasted and how many people have to suffer because of what not is being researched and developed. This sytem limits the ability to collaborate, share knowledge and build on each other’s work. The public good of scientific medical knowledge and health related technologies has been transformed into a highly protected, privatized commodity.

The COVID-19 crisis marks a critical moment for generating the change we need. But how do we go from this neoliberal capitalist logic to something else, towards a system that is driven by the needs of the public and the health of the people?

Knowledge commons

The proposal to build  a global knowledge pool for rights on data, knowledge and technologies that was presented by Costa Rica is a great example of a step in the right direction, towards transformational change. On March 23^rd, the government of Costa Rica sent a letter to the World Health Organization, calling for a Global Covid-19 Knowledge Pool¹. In his letter to the WHO, the president of Costa Rica demands a global program to “pool rights to technologies that are useful for the detection, prevention, control and treatment of the COVID-19 pandemic.” It now also enjoys the support of the WHO as well as from the UK parliament and the Dutch government and civil society, which has announced their support the idea of a COVID-19 pool as well.

Why do we need a knowledge pool and why is it transformational?

As mentioned above, under our current system the privatization of knowledge limits the ability to collaborate, share knowledge and build on each other’s work. This really is artificial because knowledge is by nature abundant and shareable. Hence the current handling of medical technologies not only limits access to the ensuing treatments, it also limits innovation.

The Covid-19 Poll would pool relevant knowledge & data to combat Covid-19, creating a global knowledge commons². It is a proposal to create a pool of rights to tests, medicines and vaccines with free access or licensing on reasonable and affordable terms for all countries. This would allow for a collaborative endeavor, and could accelerate innovation. It would be global, open and offer non discriminatory licenses to all relevant technologies and rights. As such the pool would offer both innovation and access.

Inputs could come from governments, as well as from universities, private companies and charities. This could be done on a voluntary basis but not only. Public institutions around the world are investing massively in Covid-19 technologies and all results could be automatically shared with this pool, meaning this could be a condition attached to public financing.

So, placing knowledge in a commons does not just mean sharing data and knowledge without regard for their social use, access and preservation. It means introducing a set of democratic rules and limits to assure equitable and sustainable sharing for health-related resources. As such it allows for equitable access, collaborative innovation and democratic governance of knowledge. At the same time knowledge commons could facilitate open global research and local production adapted to local context.

Placing knowledge in a commons does not just mean sharing data and knowledge without regard for their social use, access and preservation. It means introducing a set of democratic rules and limits to assure equitable and sustainable sharing

If we consider the COVID-19 pool holistic initiative that treats the knowledge as a commons, not only to accelerate innovation but also recognizing this knowledge as a public good for humanity which should be managed in a way to ensure affordable access for all, it could be transformational. In contrast to the existing Medicines Patent Pool this pool would be global and not primarily focus on providing access to exitisting technologies, but more also on innovation: developing diagnostics, medicines and vaccines.

Transformational change

Instead of proposing tweaks it is now time to challenge the idea of handling medicines principally as a commodity or product, and to propose structural changes in order to approach health as a common good.  This means referring to our collective responsibility for – and the governance of health when reframing biomedical knowledge production. Instead of leaving it entirely to markets and monopoly based business models.

For this we should move to an approach based on knowledge sharing, cooperation, stewardship, participation and social equity – in practice, this means shifting to a public interest biomedical system based on knowledge commons and open source research, open access, alternative incentives and a greater role for the public sector. Knowledge pools are a crucial piece of the puzzle.

The current COVID-19 pandemic demonstrates how it is possible to make transformational changes overnight when acting in times of an emergency. Let us use this crisis to acknowledge the failures of today’s biomedical research model and usher in the systemic change needed. The world after Corona will require the consideration of alternative paradigms –  it is indeed, as Costa Rica, Tedros and now the Netherlands as well rightfully confirmed – time for the knowledge commons to flourish now.

For some more background about commons thinking in the field of biomedical R&D and possible alternatives to ensure access to medicines for all, read our our policy paper ‘From Lab to Commons’. See also last year’s work on ‘The People’s Prescription’ by our allies in the UK, in cooperation with professor of Economics Mariana Mazzucato.

1. The idea of a knowledge pool is to organise the governance of knowledge by pooling intellectual property, data and other knowledge. This can accelerate the development of health technologies and thus stimulate affordable access to the public. In 2010 the Medicines Patent Pool was set up as a response to the unequal access to HIV/AIDS treatments in developing countries. It has proven to be a great success and now functions as a United Nations-backed public health organisation working to increase access to medicines for HIV, Hepatis c and Tuberculosis.
2. Knowledge commons refer to the institutionalized community governance of the sharing and, in some cases, creation, of information, science, knowledge, data, and other types of intellectual and cultural resources.

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First, a little background (from an excellent NYT article on the topic). OpenBiome is a Cambridge, Massachusetts stool bank that provides people with bottles of a “mud-colored slurry” used in fecal transplants. In recent years, physicians have made the amazing discovery that transferring the microbiota of healthy donors into the guts of people with certain illnesses can rescue them from death’s door and cure them. OpenBiome assists in this process by collecting stool donations from the public, processing them in safe and reliable ways, and making them available to patients and doctors for F.M.T., or fecal microbiota transplantation.

Tens of thousands of people suffer from the bacterial infection Clostridiodes difficile, or C. diff, for example. Fecal transplants have proven to be effective in 80% of these patients. Some feel much better within hours. Working as a nonprofit, OpenBiome helps such people by producing between 900 and 1,000 fecal transplant treatments each month, for about $800 apiece.

But now many pharmaceutical companies see fecal transplants as the Next Big Thing: a new way to deliver their drugs to treat diabetes, cancer, obesity, autism ulcerative colitis, and Alzheimer’s and Parkinson’s diseases. As the Times put it, “Human feces, it turns out, are a potential gold mine, for both medical researchers and drug makers.”

Based on the huge success of fecal transplants for C. diff, drug companies would love to extend and control this drug-delivery system for other diseases. Naturally, this would mean pharmaceutical companies destroying the fecal transplant commons and creating a new market order that they could dominate.

Ah, but how to achieve this goal? Answer: Through the strategic use of government regulation.

If the Food and Drug Administration can be persuaded to classify fecal transplants as a “drug” (rather than as organs, tissues, or blood, or some entirely new category), then FDA regulations would greatly favor drug companies and markets as the way to provide fecal transplants. The US Government would in effect create a regulated market for feces, to the exclusion of other potentially reliable, safe, and affordable options, such as commons.

Naturally, policymakers are not likely to regard a fecal commons of the sort facilitated by OpenBiome as the preferred option. Pharmaceutical companies don’t like that kind of competition, and Big Pharma calls the shots in Washington. In the name of rigorous health and safety, federal regulation is likely to be invoked by industry as the most effective way to invent a new market for itself. This would eclipse OpenBiome and preempt the idea of a viable fecal commons.

The drug industry would surely find this option attractive because it is currently having trouble getting patients to participate in clinical trials for fecal transplants – a necessary step for getting FDA approval. Sidelining OpenBiome could only help. The FDA has already stepped up its oversight of OpenBiome, which has caused its prices for fecal treatments to double to $1,600. It doesn’t take much imagination to see how prices would soar much higher — and OpenBiome would suffer — if Big Pharma truly got its claws into this market, selling our own excrement back to us as branded product.

In short, we may be about to witness an historic moment — the market enclosure of human excrement as a medical treatment. Or as one gastroenterologist put it, the rise of the “poop drug cartel.”

Such enclosures are a familiar pattern of capitalism. To meet an important need, commoners demonstrate the feasibility of an innovation through their hard work and mutual aid. Then for-profit businesses swoop in to monetize, privatize, and marketize everything. Commoners lose control of what is theirs, pay more for what they used to get for free or inexpensively, and suffer under the extractive terms of a market order, with the blessings of industry-friendly regulation.

Another path is feasible, but will the FDA make it illegal?

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Today Commons Network publishes a new policy paper that takes on the pharmaceutical system and presents real alternatives, based on open source research and the knowledge commons. Commons Network proposes a new vision for the biomedical research system that safeguards universal access to affordable medicines and scientific advances.

Taking the commons perspective allows us to offer a diagnostic of our biomedical innovation system and to put forth a political programme for a transition to a new public interest model. The EU’s market-dominated pharmaceutical policies are sized up from the ‘outside the box’ viewpoint of the common good.

This paper responds to the questions: How does the present pharma model work in Europe, what is wrong with it and what can be done right now to change it. This includes a comparison between the existing model, positive transitions and the transformative commons model with practical examples, principles and outcomes.

The paper also describes a broken pharmaceutical system, that in its current form prevents millions of people in Europe and around the world from getting the medicines they need. It goes on to show how ‘Big Pharma’ creates artificial scarcity by enclosing scientific knowledge resources which could easily be abundant and universally accessible.

The skyrocketing prices of medicines and the lack of affordable access to treatments are key traits of our pharmaceutical system. We are told there are no alternatives. This is not the case. There are alternatives to the current broken pharmaceutical innovation system that do not thrive on high prices nor the privatization of knowledge. Some of these alternatives are already in place on a small scale. Yet policy will have to support a transformation of the entire system for it to be sustainable, efficient and just.

The of medical treatments and knowledge based on patent monopolies, regulatory capture and unfair trade rules means a ‘tragedy of the anti-commons’ where over-medication and under-treatment are two sides of the same coin.

The solution to this conundrum of problems is to unleash the potential of the commons. In short: let’s commonify health-care treatments. We have to unlock the gates around medical knowledge and allow it to be governed democratically both by scientists and citizens as a whole.

This new paper by Commons Network presents the commons approach to biomedical innovation at a time when a new comprehensive approach is so direly needed. The biomedical commons represents a paradigm based on the sharing of knowledge, cooperation, stewardship, participation and social equity.

You can download the summary here,

Or you can read the entire paper embedded in Commons Network’s website.

For more information or collaborations please contact Sophie Bloemen at [email protected] or [email protected]

Photo by mag3737

The post From Lab to Commons: Shifting to a Biomedical System that’s in the Public Interest appeared first on P2P Foundation.

Ruby Irene Pratka: According to the World Health Organization, more than 420 million people around the world — including over 29 million Americans — have diabetes. People with diabetes are unable to naturally produce sufficient insulin, a hormone that regulates blood sugar in the body. Over 90 years ago, Canadian scientists discovered a way to extract the hormone from pigs and cattle and purify it for human use. Then, in the 1970s, scientists used a new “recombitant DNA rechnology” using human genes and bacteria to make insulin.

Problem solved, right? Wrong, say increasing number of doctors in the U.S. Insulin is one of fewer and fewer drugs for which no generic version is available. According to an NPR report from 2015, as these more expensive, new drugs became available, the older ones left the market. The bill for uninsured patients can be several hundred dollars per month — as a result, one Baltimore doctor told NPR that some of his patients had stopped taking the drug altogether, putting their health at risk.

Anthony DiFranco and his team at Oakland’s Counter Culture Labs are hoping to change that. DiFranco is a medical researcher, self-described bio-hacker, and cofounder of the Open Insulin Project. He has Type 1 diabetes himself. DiFranco and his team are working on a protocol to extract insulin from genetically engineered yeast cells and produce a generic drug at a cost of around $10 for a month’s supply. He says users could even eventually produce the drug in their homes. The project has created a definite buzz, raising nearly $17,000 in a crowdfunding campaign on the science-oriented crowdfunding platform Experiment.

Shareable caught up with DiFranco to learn more about the Open Insulin Project and the team’s mission to make diabetes management affordable.

Ruby Irene Pratka: How long have you been involved with the biohacking movement?

Anthony Di Franco: I got involved first in about 2011, with the founding of Counter Culture Labs. A year before that, I had worked on the founding of our sister hacker space, which deals with computer technology, and I wanted to explore ideas related to diabetes. A friend of mine had been doing research on the security of insulin pumps, and I originally wanted to [build] a DIY secure pump, but then people started thinking about founding a biohacking space, and I started rethinking my original idea.

Why insulin?

At the time, I had already had diabetes for five years. I had seen that progress was essentially non-existent — now it’s been 12 years and that hasn’t really changed. One major vendor did release a more secure [insulin] pump, but that was because hackers had pulled ahead and were putting pressure on them. If you want anything done you have to do it yourself. While I was looking into that, I saw a blog post on do-it-yourself thyroid hormones and met with a researcher who was able to get me up to speed on the chemical aspects of making [hormones] manually and potentially automating the process further down the road. We had a successful crowdfunding campaign and started actual lab work in January 2016.

Considering that close to 30 million people in the US alone live with this disease, you would think someone would have tried this before now. Why haven’t they?

I can only speculate on the reason, but it’s undoubtedly a lot of work. Many people seem to be afraid of having to deal with regulatory requirements that cost big companies millions. Insulin is one of the last holdouts where there is no generic version of the drug after more than 90 years. There are low-cost producers in other countries, but Western producers are very good at holding onto the [domestic] market. In some cases, drug companies have paid generic manufacturers not to produce drugs. The big producers are determined to keep their oligopoly.

Chemically, what is insulin? What are you building in the lab?

It’s a very small protein. In the lab, you need to introduce a gene into some organism so it creates the protein, and then find some way to extract it. We started with a protocol to make it in E. coli bacteria, but bacteria lack the sophistication to modify or secrete proteins, so the protein we extract is proinsulin, which still needs to be modified into the active form in the lab. We were looking at just making the proinsulin and making small changes to it that would allow us to complete the other steps in vitro… Now that we have some people on board with expertise in yeast engineering, we’re thinking about moving [the production] to yeast. With yeast cells, you can engineer them to secrete insulin, instead of having to extract proinsulin from dead cell debris [as with the bacteria cells]. Then you can purify [the insulin] from yeast, which is a relatively simple task. That’s what we’re focusing on. We’re still just making proinsulin as a first step and working on engineering the yeast to do everything for us. Our final product will be a strain of yeast cells that secretes insulin. Once we succeed, we will share what we come up with and build something that works for the long term.

Why is it so expensive? 

Markets are the main reason. It’s not that expensive to produce. For me, a month’s supply would cost about $10 to produce, but I’m paying about $1,000 before insurance and still $75 after insurance. If people were paying $15 for a drug that cost $10 to produce, that would still be a very healthy profit margin.

Tell us a bit about the work that has gone into this.

Most of it was just persistence. Some weeks there was very little to do in the lab and some weeks there was much more. Right now the yeast experts are the ones that are always in the lab, and I’m doing the organizing. It has been a lot of work, and we have had quite a few people coming and going, but it’s important enough to enough people that we always have enough people to keep moving it forward. A lot of our volunteers have just finished school and have the perfect science background, and they see it as doing something cool for a good cause.

What remains to be done to get the yeast-produced insulin into circulation?

We need to compete the yeast engineering, figure out a technique for purifying it and then look at the next step — how to set up a low-cost manufacturing operation and get over all the regulatory hurdles. That would require more money and more organizational sophistication than we have now, but hopefully by then our case will speak for itself and we will be able to prove we have the technology and it is usable. It will not be a for-profit undertaking.

How do you plan to test this? 

First we’ll have to verify that we have created insulin, then we’ll use standard techniques to purify it. From a regulatory point of view, if you’re making an existing drug, you just have to demonstrate that you made the right drug, you don’t have to demonstrate its efficacy all over again. We would just have to show that we made the right [chemical] sequence. We may have to do a receptor-binding study but we’re not going to worry about that right now — we will just focus on making a form of insulin that has been in common use.

A lot of the media coverage of your efforts has referred to “home-brewed insulin”— is that accurate? Are people going to be able to cook this up in their homes?

I don’t know if it will be economical to produce it in your home, but it’s not out of the question. At some point, someone will develop a protein-purifying machine which can be distributed to pharmacists or taken out into the developing world. The technology exists but the engineering work still has to be done.

What is your timeline? When do you hope to be able to distribute generic insulin?

Three or four years from now is a realistic timeline, but I hope we can do it a year or two sooner. I’m hoping we’ll have the yeast strain that does all the work soon, and then we’ll raise money to actually produce the product.

How do you react to the wave of support that you’ve gotten via the crowdfunding initiative?

It has been really encouraging. Although some people have dismissed the whole thing as impractical, a lot of other people have seen the value in it.

What motivates you about this experience?

It has confirmed what I know as a person with diabetes. The establishment views and treats diabetes and diabetes patients as a means of making money, and not as a group of people who need to be cured of an ailment. People are desperate for something they can afford. A significant number of the people who supported us have been people with diabetes who couldn’t afford their own insulin. They gave us 25 bucks to see if we could come up an alternative to these oligopolies. You realize how many people are desperate even in the Western world. By making the market competitive for insulin and eliminating these absurd profit margins, we want to contribute to the realignment of incentives in health care. We’re watching people slowly degenerate due to this condition [and] I’m skeptical about whether the economic landscape incentivizes a cure in the short term. If projects like ours give people access to drugs, in the long term they collapse the market and [incentivize] getting a cure out there.

Header photo courtesy of Anthony Di Franco.

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Medicine is the end-all, be-all argument of industrial society. I deal with this extensively in “The Foundations of Wildist Ethics,” where I argue that while the normative science of wildists is conservation, the normative science of humanists is clearly the modern field of medicine. Whereas conservation concerns itself with nature and wildness, medicine concerns itself with health and well-being. In certain formulations these medical concerns are an ineradicable and necessary part of the human condition: we humans are concerned with those we love and are of course concerned with our survival, so we hope to mitigate the troubles inflaming those concerns or even to annihilate the obstacles inherent in our existence by healing our sick. The problem, then, isn’t medicine per se.

But modern medicine and civilized medicine more broadly has gone beyond this base concern, and pervasive in its ethics journals and its practice is the idea of progress—of improving human well-being by modifying nature accordingly. For instance, the editor for the Journal of Medical Ethics, when asked about designer babies, has said he supports it because we have a moral obligation to create “ethically better children” (Alleyne, 2012).

Indeed, in the realm of ideas, the great test of the conservationist challenge is whether or not it can successfully pave the way for its challenge to modern industrial medicine. Biotechnology is argued for on the basis that it improves human well-being, and for the great advances it will offer to medicine and agriculture. In fact, with the deterioration of soil caused by industrial agriculture, biotechnology is about the only viable civilized solution; and with the advent of anti-microbial resistance, biotechnology will be the only thing to save practical medicine. Industry as a whole has greatly improved human ability to fight disease (DeBold & Friedman, 2015) and undoubtedly the collapse of industry will return to many people’s daily life the constant fight with disease that pre-industrial peoples, though to a lesser extent primitive peoples, faced.

But more than any other argument employed by polemicists for industry, industrial medicine embodies the core reasons for conservationist revolt. One reason is obviously its progressivism. But its internal logic is also the same.

Consider, for instance, the fact that most diseases are exacerbated by civilization. As one article put it, “…a developing model of infectious diseases—AIDS, Ebola, West Nile, SARS, Lyme disease—[reveals that they] don’t just happen. They are a result of things people do to nature.” It goes on to explain, “Sixty percent of emerging infectious diseases that affect humans are zoonotic—they originate in animals. And more than two-thirds of those originate in wildlife” (Robbins, 2012). The famed science and nature writer David Quammen (2014; 2012) released a book about the very issue not too long ago entitled Spillover, a follow up of some of the same issues brought up in his book on Ebola. In fact, the ideas are gaining so much steam that a revisionist faction of the movement has formed called conservation medicine, which is, as is to be expected, more medicine than conservation.

And this is not just relevant to industrial civilization. The onset of agriculture, for instance, brought massive waves of disease that only later began to be quelled through management, cities, states, and so forth—quelled, that is, by civilization (Diamond, 1999). This isn’t to say that primitive peoples did not suffer from diseases, but civilization did make things worse, and doesn’t suffer from the consequences of its actions only because of a constant fight against the microbial barbarian hordes smashing against its walls. Quammen (1981), again, explains the consequences of civilized practices without these walls:

Clear the vegetation from the brink of a jungle waterhole, move in with tents and cattle and Jeeps, and the Anopheles gambiae, not normally native there, will arrive within a month, bringing malaria. Cut the tall timber from five acres of rainforest, and species of infectious Aedes—which would otherwise live out their lives in the high forest canopy, passing yellow fever between monkeys—will literally fall on you, and begin biting before your chainsaw has cooled. Nurturing not only more species of snake and bird than anywhere on earth, but also more forms of disease-causing microbe, and more mosquitoes to carry them, tropical forests are elaborately booby-trapped against disruption.

The native forests peoples gradually acquired some immunity to these diseases, and their nondisruptive hunting-and-gathering economies minimized their exposure to mosquitoes that favored the canopy or disturbed ground. Meanwhile the occasional white interlopers, the agents of empire, remained vulnerable. West Africa in high colonial days became known as “the white man’s grave.”

In fact, most hunter/gatherers are neither struck by degenerative disorders or diseases to the degree industrial humans are, nor are they struck by many now-prominent mental health issues. One article explains, “There is increasing evidence that the resulting mismatch fosters ‘diseases of civilization’ that together cause 75 percent of all deaths in Western nations, but that are rare among persons whose lifeways reflect those of our preagricultural ancestors” (Eaton, Konner, & Shostak, 1988).

But of course this is not sufficient as a challenge to industry. As the field of conservation medicine has shown, merely pointing out that civilization exacerbates the problem of disease will only motivate progressivists to improve civilization. Instead, the process of progress itself has to be delegitimized.

A toilet requires division of labor, infrastructure and police forces for its functions

I explain, for instance, in “The Foundations of Wildist Ethics” that because artificial intervention of natural processes through civilized technics is so greatly misaligned with those natural processes, civilized institutions and management schemes must then “fill in the gaps” to preserve its edifices. This is why, left to its own devices, artifice crumbles, and why civilized institutions like the police, surveillance systems, and industrial medicine are necessary to preserve the civilized way of life. I give the humorous example of pooping: a hunter/gatherer poops and it is dealt with naturally; a toilet, however, requires division of labor, infrastructure, police forces to protect that infrastructure at a certain level of complexity, etc. A civilization is this process magnified a thousandfold.

The most potent challenge to this is the value of wildness. For instance, in the case of human health, civilized institutions cause problems that through progress can only be quelled through artificial means: further modification of human bodies, the creation of artificial desires, etc. Of course, “artifice” does not make one impure, and no person would suggest the ridiculous idea that things need be totally natural. But if the domination of artifice is called into question and value is placed on less human and technical control, or more wildness, then no civilized solution can be proposed and maintain itself as legitimate.

Note the distinction between this approach and the one of many other anti-industrialists. The latter group sometimes explains that the same process of progress is what has historically lead to collapse, since, as Tainter points out, at some point the artificial energy required to maintain civilized institutions reaches the point of diminishing returns. Because civilization is nothing but a big bubble of artifice, when it pops all the consequences from which it is able to shield its constituents when it is strong come flooding in. Thus, in the case of disease we may be solving some problems now, but we court larger disaster later, as many have pointed out may be the case with anti-microbial resistance (World Health Organization, 2014).

Of course this is true, and it should be pointed out. But because it doesn’t get to the actual root of the problem (i.e., progress) it is susceptible to being derailed by discussions like whether or not collapse is inevitable, for if it is not then we need not worry about the bubble popping. Instead, in discussions about medical technology, we should challenge the most precious values used to justify it, and we should not argue that medicine will or may, in the long run, betray its own values. Those aren’t our values anyway.

The post Hospitals and Medicine appeared first on P2P Foundation.

“Between the 15th and 19th centuries, the rich and the powerful fenced off commonly held land and transformed it into private property. Land switched from a source of subsistence to a source of profit, and small farmers were relegated to wage laborers. In Das Kapital, Marx described the process by coining the term land-grabbing. To British historian E.P. Thompson, it was “a plain enough case of class robbery.”

More recently, a similar enclosure movement has taken place. This time, the fenced-off commodity is life-saving medicine. Playing the role of modern-day lords of the manor are pharmaceutical corporations, which have taken a good that was once considered off-limits for private profiteering and turned it into an expensive commodity. Instead of displacing small landholders, this enclosure movement causes suffering and death: Billions of people across the globe go without essential medicines, and 10 million die each year as a result.

Many people curse the for-profit medicine industry. But few know that the enclosure erected around affordable medicines is both relatively new and artificially imposed. For nearly all of human history, attempting to corner the markets on affordable medicines has been considered both immoral and illegal.

It’s time now to reclaim this commons, and reestablish medicines as a public good.

Most of us define public goods broadly. We use the term to refer to benefits like law enforcement, street lights, and mass transit, which are collectively provided and deliver shared value to all. Economists narrow down that definition somewhat, saying that public goods are non-rivalrous and non-excludable in their consumption.

Non-rivalrous means that any one person can benefit from a good without reducing others’ opportunity to benefit as well. My eating an apple prevents you from consuming it, so that’s a rivalrous good. But I can watch the same TV show as you without lessening your opportunity to enjoy it as well—that’s non-rivalrous.

Non-excludable means what it sounds like: A person cannot be prevented from consuming the good in question. Clean air is a good that can be enjoyed by all without the possibility of denying access to those who don’t register or pay a fee. But access to a private swimming pool is an excludable good. The classic example of a non-rivalrous, non-excludable public good is a lighthouse: One ship benefitting from its warning doesn’t subtract from any other ships’ chances of enjoying a similar benefit, and there’s no practical way of limiting the lighthouse’s warnings to a select few.

As the English enclosure movement proved, exclusivity can be artificially created by literally or figuratively walling off common access. Exclusivity can be undone as well: The modern open-source software movement takes a good that some have tried to make exclusive—software code—and freely shares it, leading to a plethora of creative developments.

In terms of medicines, an individual pill is rivalrous, but the details of the formula for creating that pill are not. Knowledge is a classic public good, in that it can be shared widely without penalty to the original owner. As Thomas Jefferson said, “He who receives an idea from me, receives instruction himself without lessening me; as he who lights his taper at mine, receives light without darkening me.”

The public-health implications of access to medicines generate another core quality of public goods: positive externalities.

One person’s consumption of an essential medicine provides clear benefits beyond the direct consumer. Vaccines, for example, prevent the recipient both from getting ill and from spreading the disease to others. If a society vaccinates widely enough, the chain of disease transmission is broken, leading to the quintessential public good of mass immunity. Global distribution of the smallpox vaccine, for example, has led to the eradication of a disease that once infected 50 million people a year.

Even less obviously social medicines allow their recipients to better contribute to the social fabric and economic productivity of their communities. These medicines save costs for the broader society, too. When a diabetic takes insulin or a person with a risk for heart disease takes cholesterol-reducing medicine, they not only function better: They also lower their prospects of needing more expensive medical treatment, which is a cost often shared across societies.

Conversely, a lack of access to medicine causes enormous social problems in terms of contagion and economy-depressing illnesses.

So it’s little wonder that, for nearly all of human history, societies have treated medicine as a commonly held benefit. Until well past the middle of the 20th century, few countries allowed individuals or companies to hold exclusive rights to produce medicines. And governments have long been involved early and often in the pharmaceutical industry, creating the very opposite of a laissez-faire market. Most industrialized governments tightly regulate the production and distribution of medicine, while actively promoting vaccinations and encouraging safe use of other medicines. Governments are both leading funders of medicine research and top purchasers of the end products of that research.

When governments don’t take a sufficiently activist role in the field of medicines, public opinion pushes them further. In the 1990s and 2000s, advocates gave voice to passionate outrage over the devastating human cost of patent-priced HIV/AIDS medicines, which limited access to sufferers who could afford expensive treatments. US activists threw the ashes of AIDS victims on the lawn of the White House, while African activists called treatment-resistant government ministers murderers. The protests led to the dismantling of patent price barriers—and then to massive public programs to distribute the medicine at low or no cost.

Among governments and the public alike, medicines continue to be treated as a good quite distinct from consumer items like cell phones or flat-screen TVs. A human right to access essential medicines has found its way into international treaties and national constitutions. A moral claim for universal access to essential medicines has been put forth not only by faith-based organizations and civil society actors, but also by many drug developers themselves. Jonas Salk, for example, declined to pursue a patent for the polio vaccine, saying the patent belonged to the people. The creator of the first synthetic malaria vaccine donated the patent to the World Health Organization.

As Salk said in 1952: “Would you patent the sun?”

Photo by Victoria Reay

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