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My son was born in January 2020,
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shortly before the lockdown in Paris.
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He was never scared
of people wearing masks
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because that's all he knows.
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My three-year-old daughter knows
how to say "gel hydro-alcoolique."
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That's the French word
for hydroalcoholic gel.
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She actually pronounces it
better than I do.
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But no one wants to be wearing a mask
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or wash their hands
with hand sanitizer every 20 seconds.
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So we're all desperately looking at R&D
to find us a solution: a vaccine.
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It's interesting that in our minds,
-
we keep thinking of the vaccine discovery
like it's the Holy Grail.
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But there are a couple of shortcuts here
that I'd like to unpack.
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I'm not a doctor, I'm just a consultant.
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My clients focus on health care --
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biopharma companies, providers,
global health institutions --
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and they've educated me.
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We need to find the tools to fight COVID,
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and we need to make them
accessible to all.
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First, one single vaccine
will not get us out of this.
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What we need is an arsenal of tools.
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We need vaccines, we need therapeutics,
we need diagnostics
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to make sure that we can prevent,
identify and treat COVID cases
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in a variety of populations.
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Second, it's not just
about finding a tool.
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What do you think will happen
when one of those clinical trials
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demonstrates that the tool is effective?
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Do you think we can all
run to the pharmacy next door,
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we get the product,
we take off our masks,
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and we go back to French kissing?
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No.
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Finding an effective tool
is just one step in this big fight,
-
because there is a difference
between the existence of a product
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and access to that product.
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And now you're thinking,
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"Oh -- she means other countries
will have to wait."
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Well, no, that's not my point.
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Not only others may have to wait,
-
but any of us may have to.
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The humbling thing about COVID
-
is that because of its speed
and magnitude,
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it's exposing all of us
to the same challenges
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and giving us a flavor
of challenges we're not used to.
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Remember when China got into lockdown?
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Did you imagine that you
would be in the same situation
-
a few weeks after?
-
I certainly didn't.
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Let's go to the theoretical moment
when we have a vaccine.
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In this case, the next access challenge
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will be supply.
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The current estimate
of the global community
-
is that by the end of 2021 --
-
so that's over a year after
the discovery of the vaccine --
-
we would have enough doses
to cover one to two billion
-
of the eight billion of us on the planet.
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So who will have to wait?
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How do you think about access
when supply is short?
-
Scenario number one:
-
we let the market forces play,
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and those who can pay the highest price
or be the fastest to negotiate deals
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will get access to the product first.
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It's not equitable at all,
-
but it's a very likely scenario.
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Scenario number two:
-
we could all agree,
based on public health rationale,
-
who gets the product first.
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Let's say we agree that
health care workers would get it first,
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and then the elderly
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and then the general population.
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Now let me be a bit more provocative.
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Scenario number three:
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countries who have demonstrated
that they can manage the pandemic well
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would get access to the product first.
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It's a little bit extrapolated,
-
but it's not complete science fiction.
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Years ago, when the supply of high-quality
second-line tuberculosis drug was scarce,
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a special committee was established
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to determine which countries
had health systems that were strong enough
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to ensure that the products
would be distributed properly
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and that patients would follow
their treatment plans properly.
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Those select countries got access first.
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Or, scenario number four:
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we could decide on a random rule,
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for instance, that people get
to be vaccinated on their birthday.
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Now let me ask you this:
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How does it feel to think of a future
where the vaccine exists,
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but you would still have to wear a mask
and keep your kids home from school,
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and you would not be able
to go to work the way you want
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because you wouldn't
have access to that product?
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Every day that passed
would feel unacceptable, right?
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But guess what?
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There are many diseases for which
we have treatments and even cures,
-
and yet people keep being infected
and die every year.
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Let's take tuberculosis:
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10 million people infected every year,
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1.5 million people dying,
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although we've had a cure for years.
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And that's just because
we haven't completely figured out
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some of the key access issues.
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Equitable access is the right thing to do,
-
but beyond this humanitarian argument
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that I hope we are more sensitive to
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now that we've
experienced it in our flesh,
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there is a health and an economic argument
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to equitable access.
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The health argument is that
as long as the virus is active somewhere,
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we're all at risk of reimported cases.
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The economic argument is that
because of the interdependencies
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in our economies,
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no domestic economy can fully restart
if others are not picking up as well.
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Think of the sectors
that rely on global mobility,
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like aerospace or travel and tourism.
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Think of the supply chains
that cut across the globe,
-
like textiles or automotive.
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Think of the share of the economic growth
that is coming from emerging markets.
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The reality is that we need all countries
to be able to crush the pandemic in sync.
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So not only is equitable access
the right thing to do,
-
it is also the smart thing to do.
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But how do we do that?
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Let's make sure we're on the same page
in terms of what "access" means.
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It would actually mean
that the product exists;
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that it's working sufficiently well;
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that it's been approved
by the local authorities;
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that it is affordable;
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but also that there is evidence
that it works in all the populations
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that need it,
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and that can include pregnant women
or immunodepressed people, or children;
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that it can be distributed
in a variety of settings,
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like hospitals or rural clinics,
or hot climate or cold climate;
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and that we can produce it
at the right scale.
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It's a very long checklist, I know,
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and in a non-crisis situation,
-
we would likely address these issues
one after the other in a sequential way,
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which takes a lot of time.
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So what do we do?
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Access is far from being a new challenge,
-
and in the case of COVID,
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I have to say, we're seeing
extraordinary collaboration
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of international organizations,
civil society, industry and others
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to accelerate access:
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working things in parallel,
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speeding up regulatory processes,
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engineering supply mechanisms,
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securing procurement,
mobilizing resources, etc.
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Yet we are likely to face a situation
where, for instance,
-
the vaccine would need to be
constantly stored at, let's say,
-
minus 80 Celsius degrees;
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or where the treatment
would need to be administered
-
by a highly specialized
health care worker;
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or where the diagnostic
would need to be analyzed
-
by a sophisticated lab.
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So what more can we do?
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Pushing further the logic
that the global health community
-
has advocated for for years,
-
there is one additional thing
I can think of that might help.
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There is a concept
in product development and manufacturing
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that's called "design to cost."
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The basic idea is that
the cost management conversation
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happens at the same time
as the product being designed,
-
as opposed to the product
being designed first
-
and then reworked to bring the cost down.
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It's a simple method that helps ensure
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that when cost has been identified
as a priority criteria for a product,
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it's made a target from day one.
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Now, in the context of health and access,
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I think there is untapped potential
-
in R&D to access,
-
the same way that
manufacturers design to cost.
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This would mean that,
instead of developing a product
-
and then working to adapt it
to ensure equitable access later,
-
all of the items
on the checklist I mentioned
-
would be built into the R&D process
from the beginning,
-
and this would actually benefit us all.
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Let's take an example.
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If we develop a product
with equitable access in mind,
-
we might be able to optimize
for scale-up faster.
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In my experience, drug developers
often focus on finding a dose that works,
-
and only after do they optimize
the dosage or make adjustments.
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Now imagine that we're talking
of a candidate product
-
for which the active ingredient
is a scarce resource.
-
What if instead we focused
on developing a treatment
-
that uses the lowest possible amount
of that active ingredient?
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It could help us produce more doses.
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Let's take another example.
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If we develop a product
with equitable access in mind,
-
we might able to optimize
for mass distribution faster.
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In high-income countries,
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we have strong health systems capacity.
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We can always distribute
products the way we want.
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So we often take for granted
that products can be stored
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in temperature-controlled environments
-
or requires a highly skilled
health care worker for administration.
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Of course,
-
temperature-controlled environments
and highly skilled health care workers
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are not available everywhere.
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If we were to approach R&D
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with the constraints
of weaker health systems in mind,
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we might get creative
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and develop sooner, for instance,
temperature-agnostic products
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or products that can be taken
as easily as a vitamin
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or long-lasting formulations
instead of repeat doses.
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If we were able to produce and develop
such simplified tools,
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it would have the added benefit
-
of putting less strains
on hospitals and health systems
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for both high- and low-income countries.
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Given the speed of the virus
-
and the magnitude
of the consequences we're facing,
-
I think we have to continue
challenging ourselves
-
to find the fastest way
to make products to fight COVID
-
and future pandemics accessible to all.
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In my perspective,
-
unless the virus disappears,
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there is two ways this story ends.
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Either the scales tip one way --
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only some of us get access to the product,
-
and COVID remains a threat to all of us --
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or we balance the scales,
-
we all get access to the right weapons,
-
and we all move on together.
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Innovative R&D can't beat COVID alone,
-
but innovative management
of R&D might help.
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Thank you.
Erin Gregory
12/02/2020:
Title changed to "What it takes to crush a pandemic"