FAIR SHARE — "The future is already here," the science-fiction writer William Gibson said. "It's just not very evenly distributed." You could say the same for the coronavirus vaccine and its effects on the Covid pandemic. The vaccines were not and are still not equitably distributed around the world. Rich countries have a lot of vaccines — poor countries, not so much. Yet Merck says its promising new Covid pill, molnupiravir, will be different. The drug doesn't prevent Covid; vaccination is still the gold-standard defense. But the medicine does halve the risk of hospitalization and death for people who take it soon after testing positive for the disease. Paul Schaper, Merck's executive director of global pharmaceutical public policy, understands your skepticism about global drug equity, given the industry's spotty record, during the pandemic and before. Rich countries got better access to life-saving medications for diseases like HIV and hepatitis, even when the need was great elsewhere. But Merck, Schaper told Nightly, started working on how to distribute its Covid-19 pill around the world even before the company even knew if the drug would work. By the time Merck announced its promising results, it had already licensed the drug to five Indian-based generic makers, which were screened for their track records on past international distribution and their ability to move fast when regulators give the OK. Merck's agreements with the generic makers call for broad distribution to both low- and middle-income countries. And the company has been in touch with numerous governments, as well as philanthropies and global coalitions, that will make some of the decisions about where and how to spread Covid therapeutics. "We're trying to make sure that we will have timely and accelerated access for patients globally and not just access for this product in higher-income countries," Schaper said. Even some critics of the big pharmaceutical companies, like Doctors Without Borders, see the potential here — with ample caveats, given the industry's overall history. Merck is already known for one of the exceptions to that history. For years, it has donated loads of a drug called Mectizan to treat a dreadful ailment called River Blindness in Africa, Latin America and Yemen. Perhaps you know the drug by another name: ivermectin. On River Blindness, it works. Assuming that Merck's molnupiravir data holds up to review by the FDA and its foreign counterparts, the medicine is a Big Deal. It's a pill that doesn't have to be injected or infused at a hospital or clinic or kept in super-cold freezers. It's relatively easy to ship, distribute and store in poor nations. One downside: The patient needs to start taking the drug within five days of symptoms. That requires quick and affordable testing. In many countries, including the U.S., that's still a heavy lift. The prompt generic licensing is a "very positive step," said Rachel Vreeman, chair of the department of global health and the director of the Arnhold Institute for Global Health at Mount Sinai's med school, in an email to Nightly. But "the resource and access questions do not end when a generic drug is produced — even if the price for the medicine is low," she added. Getting the drug to the right patients at the right time will require spending money to improve testing access, too. Doctors without Borders' Leena Menghaney, who is based in India, told us she worries less about getting the drug to really poor countries in Africa and elsewhere than she does about getting it to the middle-income countries, places like Brazil or Thailand. You can think of the middle-income countries as the donut hole of global drug pricing. These countries are too rich to get a ton of help — but too poor to pay their way to the table where the U.S. and E.U. countries are placing their bids for a limited supply. The U.S., for instance, has already put in a $1.2 billion order for 1.7 million treatment courses — out of the 10 million Merck aims to have ready by year's end. That middle-income squeeze is one reason Doctors without Borders is among those advocating for a waiver of intellectual property rules for Covid (and beyond) — to open up generic production and access in those nations, both for acquiring raw materials to make the drugs and to get the finished products. Most of this IP debate (and the Biden administration's surprise endorsement of the idea) centers on IP waivers for vaccines. The Merck drug, Menghaney said, underscores that the rules of the game need to be changed for drugs as well. Nightly contributor Joanne Kenen, POLITICO's former health editor, is the Commonwealth journalist-in-residence at Johns Hopkins School of Public Health. Welcome to POLITICO Nightly. Reach out with news, tips and ideas for us at nightly@politico.com. Or contact tonight's author on Twitter at @JoanneKenen.
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