Some of the names have become more familiar as a result of the pandemic. Companies like Pfizer and AstraZeneca are now household names, and you’ve got a bunch of others that people have probably heard of as well, like GSK and AbbVie. Those are the individual companies.

This sector developed after World War II. There had been massive breakthroughs like antibiotics, steroids, and (slightly later) tranquilizers that were redefining our relationship as citizens with medicines. On the back of this, a bunch of corporations that owned the rights to produce those medicines consolidated massive amounts of power.

These companies had already been there before the war. But now they merged, grew bigger, and got to a market position where they essentially controlled the whole chain of a medicine’s life through research and development, manufacturing, and all the way to the point of actually selling the stuff at the end of the day.

There was a moment in the 1950s and ’60s when people realized all of a sudden that they were dependent on these companies that they didn’t really know about before. How could they know that what they were doing was safe? Why were they charging the prices that they were charging? This was a moment when we could have regulated these corporations in a fundamentally different way. But the companies fought back with a couple of arguments, which still haunt us to this day.

One argument went as follows: you might not like us; you might think we overcharge you for the medicines that keep you healthy; but imagine a world without us — a world without medicines. That was obviously a frightening thought, and it still frightens people to this day. At a basic level, the idea that these companies are producing stuff that keeps us safe protects them from the regulation that really should have been imposed on them a very long time ago.

They also told a more sophisticated story to decision-makers, arguing that they represented the cutting edge of technological development and scientific innovation in their societies. At the time, in the middle of the Cold War, they went to Western decision-makers and said, “Do you really want to threaten or undermine that? If not, allow us to keep doing what we’re doing, because we’re on your side and our strength is your strength.”

By making those arguments, they won. They convinced politicians and decision-makers — particularly in the United States, but in other parts of the Western world, too — that they actually needed to extend their power and privilege in the global economy. You had a series of changes as the 1980s and ’90s went on that gave these corporations massive power on a global level.

What is the basis of that power? What do these companies today share in common? You have a small number of companies, getting smaller all the time through mergers and acquisitions, while the power of individual companies is getting bigger and bigger. But they’re not really competing against each other in any normal sense, in terms of the medicines they’re producing, because they enjoy literal monopolies over production through intellectual property rights, patents, and trade secrets. That has become central to the super-high profits of this industry.

When you talk about Big Pharma, the idea of intellectual property is absolutely key to understanding its power. The companies have developed business models around making their monopolies as rigid, enforceable, and expansive as possible, because they have realized — particularly from the 1980s and ’90s onward — that this is where their money comes from.

In turn, that has changed the way the sector operates. When we think back to the 1960s, while these companies sometimes behaved in appalling ways in terms of how they marketed or tested their drugs, nonetheless, they did real research and development. That has become much less the case in subsequent decades through the development of a financialized economy in which they realized that their power came from the monopoly rights they enjoyed on certain drugs.

That has changed the way the pharmaceutical industry thinks about its relationship with the rest of society. When we talk about Big Pharma today, it’s all wrapped up in the idea that you’ve got a bunch of companies which are literal monopolists and which will sit upon the knowledge — knowledge they have usually acquired from others — and max it out for the good of their shareholders to extract as much as they can, regardless of what the consequences are for the rest of society.

I’ve talked about their addiction to super-high profits, which are based on monopolies. This is an incredibly profitable industry — three times or so in excess of the normal profit rate that big companies can expect to make. They enjoy monopoly privilege, but they don’t make these super-high profits off just any old monopolies. They’re very careful about which drugs they decide they’re going to buy the rights to produce.

The drugs that they particularly like relate to the treatment of chronic conditions. A serious but chronic condition that requires treatment is absolute gold dust to these companies, because it’s not going to cure you. You’re going to need to be on this drug for a very long time, if not for the rest of your life. If that chronic condition is suffered by somebody who happens to be protected by a health system, or by people who are particularly wealthy, then that’s great — they or the health system can afford to pay large amounts of money for the rest of their lives.

The other blockbuster area is cancer treatment. The prevalence of cancer is increasing as we live longer in richer countries, and that is seen as a particularly lucrative area. They specialize in these areas where they think they can make very large amounts of money. They buy up the knowledge and begin producing drugs, charging eye-watering amounts for them.

It is not unusual nowadays to have new drugs coming onto the market that can accrue something like $100,000 per patient, certainly in the US. Even for the health system of rich countries, this is enormously expensive. That is their ideal situation.

What has come to be called research and development today is actually time and effort spent doing what the companies refer to as “evergreening” these drugs. You’ve got a monopoly on production of this drug, but it’s still going to run out after twenty years. How do you extend that?

They will make very small tweaks. They’re not really making them any more effective, or any more pleasant to take for the patient. They’re making small changes that they can sell as an improvement, and then they reapply for the monopoly on the grounds that it has changed just enough that they deserve another monopoly for it. You see that happening time and time and time again.

The worst example that I came across was a company that literally put a powder pill into a plastic capsule and then applied for another monopoly on it. That means you’ve got several more years in which you can continue charging whatever the market will bear. This is obviously not good for us as patients, because it means that the companies that are producing our drugs are not focused on the diseases that kill most people.

You’ve still got diseases in the world like TB and malaria that are killing enormous amounts of people. But they attract very little interest from the Big Pharma companies because by and large, the people suffering from those diseases are poorer people in poorer countries. You’re not going to make super-high profits in those circumstances.

Even coming back to the Global North, they’re not really interested in pathogens that could cause pandemics. Just look at what happened before the COVID-19 pandemic: no Big Pharma company was looking into coronaviruses, even though they had already caused epidemics in other parts of the world. There was very little work done on any pathogen that could cause a future pandemic despite warnings from the World Health Organization. The companies were just not interested, because it was very unlikely that any particular pathogen was going to cause a pandemic, so it was a waste of money as far as they were concerned.

The same goes for antibiotics. Antibiotic resistance is growing all the time, partly through overuse, but we haven’t invested very much as societies in creating alternatives to antibiotics, even though we think it’s perfectly possible. Again, this is because the pharma industry is not particularly interested in something that is going to be used as a second- or third-generation drug. By the time that drug becomes mainstream, the patents are going to have expired, so they’re not interested in that.

The drugs that we need to have developed for the future or to save lives now are not particularly interesting for the pharmaceutical industry. The drugs that can treat chronic conditions suffered by richer people in richer countries are more interesting to them because those companies think that they are going to be able to charge vast amounts of money for those drugs.

This massively skews which medicines are being developed. For a long time, governments have recognized that the pharmaceutical industry is not really doing the job that we want it to do. That’s why you’ve got massive public investment in the development of medicines, particularly in the United States.

You also have a number of public philanthropic organizations at a global level because there’s a recognition that the pharmaceutical industry is not going to solve the diseases of poverty in the world. That even goes for someone like Bill Gates, who in general is very supportive of the intellectual property system, because that’s how he made his money. Gates has set up several philanthropic organizations to try and correct the shortcomings of the market in that regard.

At the same time, however, we are still reliant on these companies. We haven’t put anything else in place, so they ultimately control the pipeline. That’s what you saw during the pandemic: we recognized that they couldn’t really do the job, but we didn’t have an alternative because they still have a choke hold on the production of medicines at a domestic level in Western countries, and to some degree at a global level, too.

Almost all new drugs rely enormously on public funds, particularly at the riskiest stage of development. We’re told a story about the ingenuity of the private sector and how we’re dependent upon the entrepreneurship of corporations. What you actually find when you look at medicines is the complete opposite of that.

All of the innovative work is done with public money, either at universities or by small biotech companies. The Big Pharma companies then privatize and enclose that knowledge and use it to produce the drugs that they think are going to make them the most money. They enclose that knowledge behind a wall of intellectual property for as long as they can possibly get away with and charge whatever the market will bear.

When you look at what the pharma companies are actually engaged in with research and development, compared to the past, their R&D budgets have reduced in proportion to their overall spending. Even when they say they’re doing research and development, what they’re often doing is “evergreening” so they can extend the monopoly rights and ward off competition from generic producers to maintain their position.

The extraordinary thing is that the governments that allow that knowledge to be privatized and enclosed don’t seem to have got their heads around the situation. By simply handing that knowledge over to the Big Pharma companies, you are going to end up with a system that may not produce the most important medicines that you need, and certainly not at a price that you can afford to buy them.

To give you one example, there is an anti-inflammatory drug called HUMIRA, which is very useful for dealing with rheumatoid arthritis and Crohn’s disease. It wasn’t invented by AbbVie, but AbbVie bought a company that had the know-how for producing it, based on public sector investment. AbbVie then spent a few hundred million dollars, or maybe even a few billion, supposedly on research and development around HUMIRA. But they didn’t make the drug any more effective or more pleasant for patients to take. They then increased the price by 470 percent.

What it seems they were doing with that R&D money was working out ways that they could extend and deepen their monopolies on the drug over the long term and create what are called patent thickets. You don’t have just one patent that says you have the right to produce this drug — there’s a whole thicket of different patents. In the US at one point, HUMIRA treatment cost about $77,000 per patient. Even in Britain, the National Health Service had to ration the drug because it was so astronomically expensive.

One of the biggest scandals that people are aware of at the moment, particularly in the US, is the opioid epidemic. This is a really shocking story where a company called Purdue Pharma, owned by the Sackler family, created an ultrastrong painkiller. It was not that far removed from heroin and should have been restricted to the most serious end-of-life pain.

The company then went out and used all of the marketing tools at its disposal to convince medical practitioners across the US that this was something that everybody should be taking if they were experiencing even the mildest forms of pain. Purdue went out of their way to convince people that it wasn’t addictive when it was clearly extremely addictive. This involved corrupting academics and medical professionals.

The end result was a wave of drug addiction and dependency that saw up to three hundred thousand people die in the United States over the last two decades. It was a horrific public health crisis that has exacerbated the existing dislike and distrust of the pharmaceutical industry and played a very important role in bringing about some of the changes that you’re beginning to see at a federal and state level in the US.

That is a terrible scandal. But it’s quite an old-fashioned scandal, in the sense that Purdue Pharma did actually invent OxyContin. Increasingly, we are living in a world where the pharmaceutical companies don’t actually do the basic R&D or invent the drugs that we are dependent upon. A more modern scandal was the one involving Martin Shkreli, a young guy who became known as the Pharma Bro.

Shkreli came from the hedge fund world — he was a financier. By his own admission, he got out of hedge funds because there wasn’t enough money to be made. Instead, he decided to start a pharmaceutical company because that was where the real money was. He would look for drugs where there was a monopoly — not necessarily a patent monopoly, but certainly a de facto production monopoly that it would have taken other companies a fair while to break.

Shkreli would identify those drugs, buy them up, and then put up the price as much as he could possibly get away with. He bought up a drug that was used to treat a horrible parasitic infection in people with HIV which sometimes affects pregnant women. He increased the price by 5,000 percent overnight, knowing that people had nowhere else to go — they’d have to pay it.

He became the most hated man in America, managing to unite Bernie Sanders, Hillary Clinton, and Donald Trump in their dislike of him. But he gave a number of interviews where he more or less said the following: “Look, I’m getting all of this terrible publicity, but I’m not doing anything that differs from what the rest of the pharmaceutical industry is doing. My job is not merely to make my investors a bit richer. It’s to maximize the profits that I’m returning to those investors. If I have one regret, it is that I didn’t increase the price further because I probably could have done, and therefore should have done.”

Shkreli has become a hate figure — almost a pantomime villain — because he does all of this with a smirk on his face and he’s quite proud of it. But he’s absolutely right: he may be an extreme case, but ultimately the model that he’s employing is not that different from the model that is completely mainstream in the pharmaceutical world at this point.

This was a very interesting moment because just before the HIV/AIDS crisis, Big Pharma had convinced governments that their monopolies should be global. One of the first agreements that was endorsed by the newly formed World Trade Organization was the TRIPS [Trade-Related Aspects of Intellectual Property Rights] agreement, which stated that the framework of intellectual property rights should be the same everywhere in the world as it currently was in the United States.

This was an enormous change. Bear in mind that most European countries didn’t have patents on medicines in the late 1970s. The UK and Germany did, but a lot of other countries didn’t. In the 1960s, Harold Wilson’s Labour government in Britain overrode patents on antibiotics and imported them from Italy, where there were no medical patents, because they could save a lot of money for the [National Health Service] in that way.

In the mid ’90s, very few countries in the Global South put patents on medicines, which was very important for them because it meant they didn’t have to reinvent the wheel. They could look at what had been done elsewhere and start pumping out medicines at a much lower price, particularly in India, where there was a good manufacturing base.

That all changed with the passing of TRIPS, which has been called a recolonization of knowledge at a global level. All of a sudden, those countries had to start thinking about how they could abide by US levels of intellectual property, respecting intellectual property rights that were by and large held by Western corporations.

The HIV/AIDS crisis came to a head a few years after that. In South Africa, during the late ’90s and early 2000s, phenomenal amounts of people were contracting HIV and dying of AIDS. For those people, HIV was more or less a death sentence at the time, despite the fact that we had the drugs to prevent the transmission of HIV from mothers to children and to extend your life indefinitely. Those drugs weren’t nice to take, but at least we had them.

The problem for people in Southern Africa was that they couldn’t afford them. It cost something in the region of $10,000 per patient, which was simply unaffordable for almost everybody in that context. The [African National Congress] government said, “We need to look at how we can get around this.”

They knew that those pills were being made generically for a dollar per pill in India. But South Africa, because it had adopted the elements of the TRIPS agreement that protected intellectual property, wasn’t allowed to import them.

They tried to pass a law that would have made it possible to import these medicines, whereupon thirty-nine pharmaceutical corporations slapped a lawsuit on them and accused them of pirating their intellectual property. Eventually those corporations backed down, because there was a huge international campaign against them. Nonetheless, it sent a chill down the spine of all developing countries, who were put off developing their own medicine industries because they didn’t want to be in the same position as South Africa.

The pharmaceutical corporations were backed by Bill Clinton’s administration and the European Union at the time. They were all saying, “You can’t do this,” even though it was going to make an enormous difference to the spread and impact of HIV. South Africa overcame the pressure thanks to international campaigning, but this set a very serious example for the future.

When it came to COVID-19, this was one of the reasons that so few countries have managed to develop decent medical industries that could help get vaccines out to people in a timely way. There were only a few countries like India and China that could do that because to one degree or another, they had ignored these international rules that came into effect during the mid ’90s.

But there is an important point to note here. It is still possible for countries to do what South Africa did. India has always interpreted the intellectual property rules in as relaxed a way as it possibly can, which is how it remained the pharmacy of the developing world — so many countries are still dependent on Indian medicines.

Countries are still doing it. Colombia took a very brave decision earlier this year in relation to HIV drugs. They said, “We just can’t afford these drugs — we can’t afford to give them to all of our people — we are going to override these patents and import them from India.” They’re still going through a process of trying to achieve that, although they’re getting a lot of pushback. The company that they’re fighting against is called ViiV.

Another legacy of the South African HIV controversy is that pharmaceutical companies got to be much better at PR. All of a sudden, they realized that the question of whether they could get away with something or not depended on how the international public and civil society felt about it. ViiV supports Pride marches all around the world and likes to pretend it’s very supportive of gay rights. But at the end of the day, it is still making drugs that are utterly unaffordable for many of the people suffering from the disease that those drugs are supposed to deal with.

I think it has, and in quite complex ways. First of all, the industry saw COVID as a great opportunity in some ways. The head of Pfizer, Albert Bourla, was quite honest about that: he said, “This is not just an opportunity for us to make money — it’s an opportunity for us to change the reputation of this industry.”

Going into the pandemic, Pfizer was supposed to be the least trusted company in the least trusted industry in the United States. They saw it as a way of becoming the savior of the world, in effect, and to some degree they managed that. There are many examples of countries like Israel where Pfizer rolled out its vaccines very quickly. There were stories of cocktails being named after its vaccines in Israeli bars because they were saying, “Without Pfizer, we wouldn’t be here.”

In other ways, however, I think the long-term results for the industry are going to be very different. COVID showed people a number of things very clearly. One is that the pharma companies do not have the best interests of global health care at heart — they have their profits at heart. That was something that Global South countries in particular experienced as a result of the fact that the intellectual property behind the vaccines was being held by a small number of Big Pharma companies.

This meant that those companies could dictate who got to produce the vaccine and who didn’t, what the manufacturers were able to charge for that vaccine, and who got to buy it. At a time when frontline health workers in many poorer countries still couldn’t be vaccinated, well into the pandemic, people in the West (like myself) had already received three or four doses.

It wasn’t simply a case of Pfizer not selling to those countries. By monopolizing the intellectual property and refusing to share it, they were telling other countries that they couldn’t make vaccines, either. We could have made many more vaccines. There was a piece of research done in the middle of the pandemic which suggested that there were a hundred factories around the world that could have produced mRNA fairly quickly if the technology and know-how had been shared with them.

The fact is, it wasn’t shared with them, and that was atrociously bad for people in Global South countries who couldn’t get the vaccines. It obviously cost far more lives than it would otherwise have done, but it was also bad for those of us in the West because the disease was able to spread for longer, resulting in mutations like Omicron that threatened to override some of the vaccines that were already available. It made ending the pandemic that much harder.

That has been recognized by Global South countries who felt that the entire approach they had been told to swallow for the last thirty years amounted to “when it comes to a crisis, just trust the market.” And if the market goes wrong for any reason, don’t worry — we’ll give you some charity to get you through.

Neither of those things happened. There were almost no donations outside the United States, and all the market did was what the market has always done — it sold where there was money to be made and ignored everybody else. I think that has created a real change in how many parts of the Global South relate to the development of medicines.

Even in the United States, I think the Biden administration was horrified, particularly by the way that Moderna behaved. Moderna’s vaccine was 100 percent supported with public funding — Pfizer also received a lot of public money, but not quite the same proportion. Although Moderna was seen as the US government vaccine, when it came to the crunch, the company refused to share, or even accept that US government scientists had anything to do with creating some of its patents.

The tensions between the Biden administration and Moderna were enormous. There was a court case taken where the government tried to claim its rights over some of the vaccine technology that they had developed.

You don’t have to be a great philanthropist to understand why that was a concern, because in the middle of the pandemic, virtually everybody in Asia, Africa, and Latin America that had received a vaccine at all had got one from China. With the partial exception of AstraZeneca, the Western vaccines were nowhere to be found in the Global South, and that has had a long-term impact, hastening the breakdown of the multilateral system. It strengthened the idea that we are divided into two separate worlds, not one multilateral system.

When you look at COVID, it is an example that we need to learn from in terms of how we deal with other crises, because as bad as the pandemic was, the climate crisis is going to be much, much worse. What we saw is that we had a global economy developed in the 1990s in the image of corporate power. It was all about forwarding corporate interests and the right to do whatever you want with your money, whenever you want, wherever you are in the world.

That system fundamentally failed us. That was very clear, as I’ve already said, for Global South countries, but to some degree, it was clear for all of us. The immense quantity of public money that we put into this ultimately served to make an absolute fortune for pharmaceutical corporations. For Moderna, several members of its board became multibillionaires, including its CEO. That was because knowledge that should really be seen as a public good was treated as a private asset.

If that was a problem for COVID, it’s also going to be an enormous problem when it comes to dealing with the climate crisis. The climate technologies that all countries on Earth will require to deal with climate change are going to be held by a handful of corporations. Most countries in the world are going to have to rent those technologies back from those corporations — in many cases, I imagine, for a very high cost.

That is no way to deal with what is probably the most serious crisis that humanity has ever faced. The rules, treaties, and institutions of the global economy, like the World Trade Organization, are not in any way set up to help us deal with the problems that we face as humanity, and we need to begin dismantling them.

One of the things we were campaigning for during the pandemic was the idea of a waiver of intellectual property on vaccines and other forms of treatment. But that was just the beginning of the campaign that we need to be running, which should say that in the middle of a climate emergency, there is no way the knowledge that can enable us to deal with that emergency should be treated as private property for a handful of corporations. That is particularly true when an awful lot of that technology has been created with massive public investment, just as was the case with COVID.

I spent a lot of my life campaigning against the World Trade Organization, against international trade agreements, and against the World Bank and the International Monetary Fund. During that period from the 1990s when the global economy was being constructed, we had a chance of stopping some of it. In the end, we did stop some of it, but nowhere near enough.

My experience of campaigning over COVID shows to me that it’s very unlikely we are going to be able to unwind that system through international negotiations at a global level. There are just too many vested interests to overcome. I think it’s going to be unwound, at least to begin with, at a national level, where countries simply begin ignoring the way that this system works.

What does that look like when it comes to medical research and development? There is a great example in South Africa called the mRNA Hub, which was set up in the middle of the pandemic with World Health Organization backing. This laboratory went to Pfizer and Moderna and said, “We need to understand mRNA technology and how it works, not only because it can help us deal with COVID, but also because it could potentially be used for immunization against TB and malaria, or to deal with HIV and various cancers.”

Pfizer and Moderna obviously said they wanted nothing to do with that initiative, but the South Africans went ahead anyway and worked out how Moderna had done it. Of course, there’s a long way to go between understanding it and actually producing a vaccine. They weren’t able to do that in time during the pandemic, but they are now working on a TB vaccine.

The truly revolutionary part of what they have done does not come from their scientific research. They went on to say that having mastered this technology, they were going to share it with governments across the world who they thought could safely make use of it. They’ve shared it with twelve other countries, including India, Brazil, and Argentina, which have the ability to scale up the technology outside the framework of the intellectual property system.

That’s a very exciting development that we should be supporting. In Western countries, we also need to make sure that the research we’re already doing, which is so important for the development of medicines, is free of intellectual property constraints. Why on earth are our tax dollars or pounds going to pay for research that ends up being owned by multinational corporations?

This shouldn’t be controversial anywhere on the political spectrum. We need to put conditions on any research we do, saying that this cannot end up being produced in a completely unaffordable way by a handful of corporations. We need a different system for how we manage that intellectual property.

In addition, there has to be some degree of public manufacturing. At the end of the day, you can do all the research and development you want. But if a country does not have the ability to put that research into a syringe or a pill that will be produced at a reasonable cost for your own health system or your own people, they are going to be able to hold you hostage.

In the most unlikely circumstances, we are seeing a recognition of that now. If you look at the state of California, it has now said that too many of its citizens cannot afford to deal with their diabetes in a safe way because of the cost of insulin. They are rationing their insulin at great cost to their health — sometimes even the cost of their life. The state authorities have put down a hundred million dollars for cost-price production of insulin that they are going to give to everybody who needs it.

There are seven other states in the US following their lead, including states run by Republicans who are saying that this system is not sustainable any longer. I think that you are beginning to see the start of a fundamentally different way of researching, developing, and producing medicines that leaves the pharmaceutical industry to one side. Now that has to go a lot further, and it has to be much more transformational than anything we have seen so far. But I think there is at least the possibility of that happening.

I was astonished when I woke up one day in August of last year and Joe Biden had tweeted “We beat Big Pharma,” because they had got the Inflation Reduction Act through and were beginning to negotiate prices of some medicines for the first time in the US. I never thought I would see a US president tweet that. Clearly what Biden has done is not enough, but it gives us as activists and campaigners an opening that we should do everything we can to exploit in the years ahead.