Framing access to medicines during COVID-19: A qualitative content analysis of Gilead’s Remdesivir

ABSTRACT

The COVID-19 pandemic calls into question the institutional structure underlying the pharmaceutical industry. While some have called for medical technologies to be global public goods and patent waivers on pharmaceuticals, much of the industry has pushed back against any attempts that might threaten their monopoly power to set prices. Public acceptance of the role of private companies to control life-saving drugs, as well as of the intellectual property system, informs campaigns guaranteeing universal access to medicines and corporate strategies to shape policy. This study consists of a qualitative content analysis of online comments about news reports of Gilead Science’s pricing of remdesivir, a re-purposed drug that shows some positive efficacy against COVID-19 in clinical trials. Analysing elite and public framing about medicine pricing informs our understanding of the social construction of markets. The findings identify hegemonic and counter-hegemonic discourse about innovation, affordability, saving lives, health care savings and international comparisons that stimulate debate and potentially advocacy. As such, the discursive context delineates the possibilities for remediating the normative and material structure of a pharmaceutical system currently geared towards private profit instead of public health needs.

KEYWORDS:

• COVID-19
• remdesivir
• access to medicines
• pharmaceuticals
• drug companies

Introduction

Access to essential medicines plays a central role in achieving public health objectives, upholding the human right to health and providing comprehensive health care. While a new therapy can transform a deadly disease, high prices for new drugs remain an obstacle to ensuring access and place significant financial burdens on the public health systems and households in both the developed and developing world (Abbas et al., 2020; Ozawa et al., 2019). The current structure to research, develop and market new medicines empowers pharmaceutical corporations to establish prices based on patent monopolies, niche markets and non-transparent practices (Lexchin, 2018; Light, 2008). Global trade regimes extending intellectual property protections have further strengthened the market position of these transnational firms throughout both the developed and developing world. Governments retain power to limit abuse in the market and adopt various flexibilities to achieve compliance (Shadlen, 2017), but only in a few circumstances have authorities implemented policies to restrict the market power of drug companies, for example, using compulsory licenses (Son & Lee, 2018).

Like other recent emerging disease challenges, COVID-19 calls into question the institutional structure underlying the pharmaceutical industry. While the World Health Organization (WHO) and others have called for treatments and diagnostics to be ‘global public goods’ and a few companies have relaxed their patent rights on potential treatments and vaccines (e.g. Abbvie and Moderna), much of industry and wealthy countries have resisted threats to the monopoly power to set prices. Nevertheless, public acceptance and/or criticism of private companies’ control over life-saving drugs inform consumer advocacy that can shape governmental policy (Burstein, 2003). The objective of this study is to answer the following questions. First, what is the nature of the discursive field that surrounds pharmaceutical companies’ determination of the price of their drug therapies? Second, how do non-elite elements of the discursive field compare with elite discourses in the news media? A qualitative content analysis of Internet comments made on Reddit and the reporting of the Wall Street Journal (WSJ) provides insight into these questions.

Hegemony and the social construction of markets

Public and elite perspectives of drug company pricing inform our understanding of markets as social constructions imbued with moral character and cultural meaning (Fourcade & Healy, 2007; Jessop, 2004). That is, capitalist rules and regulations require the active consent of the governed for their continued reproduction. In this Gramscian sense, capitalist power extends into civil society as an ideological support arguing that private incentives and control of resources is the only and best way to achieve economic and social goals. Hegemony, therefore, goes beyond strictly political and economic factors and mechanisms but involves discursive, moral and intellectual spheres throughout society (Hall, 1986; Laclau & Mouffe, 1985). Achieving active consent for the governed is not a foregone conclusion due to counter-hegemonic efforts, or in what is termed a ‘war of position’ in the Gramscian parlance. Through systemic critique, boycotts and protests of current practices, social movements attempt to disrupt and change the current institutional order. To understand whether pharmaceutical pricing receives hegemonic support or is subject to significant counter-hegemonic processes, we must examine both the rhetoric of elites and also the discursive context comprised of the general public.

While past studies have focused on the effect of elite framing by non-government organisations and business actors on policy outcomes (Sell & Prakash, 2004), increasingly there has been more attention paid to the role and impact of social movements have on markets understood as locations of social contestation (King & Pearce, 2010; McDonnell et al., 2015). Many of these structuralist accounts focus on the political opportunities for challenging elites and institutions. Problematically, such an account discounts the role of cultural factors in mobilising for action based on different moral views of the world (Jasper, 1997; Snow & Benford, 1986). For example, previous research has demonstrated the cultural bases of social movements focused on the perceived immorality of markets in people and alcohol (Young, 2006). Central to these efforts are shaming tactics and targeting stigma towards more powerful actors (Bartley & Child, 2014; Mirabito et al., 2016).

Past studies have identified various frames used in the social construction of pharmaceutical pricing, such as the role of human rights, need for innovation, rights to property, adequacy of generics, among others, related to essential medicines (Flynn & Silva, 2020; Kapstein & Busby, 2013; Owen, 2014). However, many of these studies emphasise a top-down perspective or elite-driven narrative without considering the cultural context in which elites operate. Snow (2008) has articulated the concept of discursive fields to theorise the contextual aspects of social construction that occurs through framing. The discursive field refers to both the ideational and relational elements that enable some types of frames and constrain other frames. By examining non-elite discourse, we can gain a sense of the types of frames that are permissible. In other words, which frames dominate the collective consciousness, and which are subject to significant counter-hegemonic efforts? Knowing the specific issues and frames that resonate with the public can inform consumer advocacy related to efforts to improve universal access to medicines. Conversely, debates related to medicinal access can also inform corporate strategies, either as useful advertising or means to protect economic interests (Rocha et al., 2020).

Case background

Remdesivir is the first prescription drug approved by the Food and Drug Administration (FDA) for treating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although it had failed as a treatment for hepatitis C, Ebola and Marburg virus, human trials had established its safety profile prior to the pandemic. Gilead Sciences submitted patents for the drug to treat coronaviruses in 2019, after in-vitro studies demonstrated its effectiveness against severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) (Sheahan et al., 2017). In May, the U.S. FDA authorised emergency use of the therapy, and a National Institute of Health-sponsored clinical trial of 1063 patients showed that remdesivir reduced recovery time from 15 to 11 days in hospitalised COVID-19 patients (Beigel et al., 2020). Subsequently, over 50 countries have approved emergency use of the drug, although debates about efficacy continue and the WHO (2020) recommended against its use. The latest review of the evidence concluded that remdesivir ‘might shorten the time to clinical improvement among hospitalised adults’ but only the results from an additional 23 trials currently involving 30,000 could provide more conclusive answers (Pimentel et al., 2020).

Gilead announced at the end of June a price of $3120 for the five-day treatment course in the U.S. and $2340 for other developed countries (Lupkin, 2020). Subsequently, most notably the United States, but also European Union, signed contracts securing most of the production in the ensuing months. The company also signed non-exclusive voluntary licenses with five Indian and Pakistan companies that would determine prices and pay royalties to supply the drug to 127 countries that include much of the developing world but exclude many Latin American and middle-income countries that face heavy disease burdens (Silverman, 2020). Access to medicines activists have pressured Gilead not to enforce its intellectual property claims so as to allow rapid scale-up of production worldwide (MSF Access Campaign, 2020) and have also contested its patent applications citing lack of inventive step and clarity, as in the case of Brazil (GTPI, 2020), as well as in other middle-income countries.

Methods and data

We conducted a qualitative content analysis (Altheide & Schneider, 2013) of elite and public framing of remdesivir’s price, as well as portrayals of business and political actors involved in the process. Our source of data was U.S. Newsstream from ProQuest and Reddit. Using the term ‘remdesivir’, we queried the database for articles published by the online versions of the WSJ from June 29, 2020 and September 28, 2020. The WSJ contains elite framing of the issue as it boasts one of the highest readerships in the United States (Benton, 2020) expressing a pro-business perspective (e.g. Brimeyer et al., 2016). We used ProQuest’s U.S. Newsstream dataset to collect op-eds, editorials and expert commentary published in WSJ. This search yielded 33 unique articles, of which seven contained evaluative statements.

To acquire data from less moderated elements of the public sphere we turned to Reddit – a news aggregation website that provides numerous forums for people to discuss a variety of matters. If WSJ represents the perspective of business elites, Reddit provides an opportunity for non-elite and marginalised discourse to flourish (e.g. Gaudette et al., 2020). It is the seventh-ranked website by ‘traffic and engagement’ in the United States and 17th in the world (Alexa Internet, n.d.). Using the search term ‘remdesivir’ on Reddit, we found 42 posts that potentially contained discussions about remdesivir pricing.

In keeping with qualitative methodology, the analysis of the data occurred through many rounds (Charmaz, 2014; Lofland et al., 2006). This qualitative approach is meant to uncover the meanings found in the discourse rather than to establish a count of how many types of a given argument could be found. In the first round, we coded the material for pro-pharmaceutical, anti-pharmaceutical, neutral, off-topic/unclear statements using NVivo 12 Pro resulting in 341 pages of coded material. In the second round, we selected all 304 comments that had been coded as pro or anti from 25 posts for further analysis. The majority (241) of these comments come from one post, a discussion of an article in the WSJ reporting on remdesivir’s pricing (Walker, 2020). At this stage of the analysis, we drew upon the categories reported by Flynn and Silva (2020) to analyse the material that had been coded as pro or anti. These frames about anti-corporate and anti-government views, economising public health resources, saving lives, incentivising innovation, opposing patent, pharmaceuticalisation and partisan politics, among others.

Although we began with a coding scheme from a previous study, we followed the logic of qualitative analysis and modified the categories accordingly. According to this approach, as we coded the material, we also wrote analytic memos about what we were observing and then adjusted the coding scheme accordingly. In the third round of the analysis, we examined the coded material for consistency. As we reviewed these categories, new themes emerged that had not been found in the previous study. The results of this analysis are presented below.

Findings

The qualitative content analysis provides insight into the public perception of pharmaceutical markets from the point of view of elite voices as well as from the general public. Despite the limited sample of elite opinion, our data comprised close to five pages of content expressing support for the current institutional structure compared to just over one page of anti-corporate criticism. In contrast to elite views, the majority of the content from non-elite commentators expressed an anti-industry bias, totalling 31 pages, with comments like ‘This is why we hate bit (sic) Pharma and the politicians they bribe’. Pro-industry contributions amounting to 22 and half pages included phrases such as ‘This saves money for both patients and hospitals … ’ and ‘ … it’s not a high price … ’

The second round of coding revealed the different frames used to legitimate or denounce pricing practices. Below, we analyse these hegemonic and counter-hegemonic discourses around the following four themes: role of private and public sector in pharmaceutical innovation, alleged health care savings versus the morality of pricing life-saving products, international comparisons of the U.S. health care system and cost of medicines and debates about capitalism and socialism.

Bearing the price of innovation

One of the most contested issues regarding prices and access concerns innovation. The pro-industry argument is that high prices incentivise firms to invest in the research necessary to market new medicines. Elites frequently voice this frame justifying Gilead’s price for remdesivir by highlighting the resources and efforts pharmaceutical companies expend to bring a drug to market:

Gilead expects its development and manufacturing costs by the end of the year to exceed $1 billion, including exploring an inhaled formulation that would let patients be treated outside hospitals.

Gilead's scientists are entirely responsible for the invention of remdesivir.

The statements claim the leading role the company has played in investing in remdesivir and creating innovative formulations. To fend off attacks about R&D contributions from public sources, the second statement suggests Gilead should be able to have full control over the medicine including its price. This justification also resonates with the public. In fact, many non-elite comments appear to have delved into the literature about R&D costs, failure rates and the time necessary to bring a drug to market:

Gilead spent a lot of money in clinical development in phases 1–3 including in the early phases where they established safety profile and during which the risk of failure is high. Also they assumed a large amount of risk by going all in on increasing production in January before they even knew it would work. If it didn’t work they would have assumed tens maybe hundreds of millions of dollars in losses. And no one in government or out would have gave a shit.

Even if it's the minimum, the range isn't $70 million to $1 Billion. Novel drug R&D costs about $2.6 Billion per drug. Let's say it's triple the quote you just put in. $210 million!!! that's still less than 10% of the cost to develop a drug.

Usually it takes 10–20 years for a drug to develop. And they have to cover for 15–20 other drugs that failed to reach profitability stage.

These quotes argue that medicine prices must reward the inherent risk private actors assume in drug development. In fact, one reader states that the cost to bring a drug to market is $2.6 billion, referring to a study (see DiMasi et al., 2016). In other posts, comments reference a more recent study stating that it takes about $1 billion dollars (Wouters et al., 2020).

In response to claims of the importance of private sector capital, critics highlight the role of government resources not only for remdesivir’s development but also across the whole pharmaceutical industry. In fact, one elite author highlighted how funding and contributions from the U.S. government may limit Gilead’s patent claims:

In fact, a report that one of us published in May showed that the federal Centers for Disease Control and Prevention has the strongest government claim to co-ownership of patents covering remdesivir, and the CDC has so far declined to comment on its patent rights. Interviews in the Washington Post with the CDC and ex-Gilead scientists confirm that research on remdesivir's antiviral properties was not only federally funded but performed by a CDC scientist.

If the government has a ‘claim to co-ownership’, it follows that Gilead does not possess the sole right to profit from it. This frame is also found in public discourse as several commentators questioned assertions made by pharmaceutical companies that they invest billions.

Don't pretend Gilead did it by themselves. They claim to have spent a billion but they used government facilities, scientists, and university grant recipients along the way. Gilead didn't create the drug by themselves but are setting themselves up to be the sole financial gainer from it

And the 1 billion it cost is self reported. I'd LOVE to see that itemized.

Unless things have changed drastically in the last 15 years, most major drug companies have small R&D budgets compared to marketing. Almost all of the basic science and testing is done through public institutions, such as universities, research institutions, and public hospitals.

These quotations follow the same logic as aforementioned claim found in the WSJ. Not only do many of these statements reference reports about government funding of R&D costs but also contradict the claims that the company assumed most of the risk by citing various other forms of public support.

While our content analysis focused on one string of public comments about the WSJ’s report of Gilead’s pricing remdesivir, several contributors referenced work by access to medicine advocates showing that government entities provided at least $70.5 million to develop the drug (KEI, 2020) even though the article under discussion never referenced the figure. Another contributor even copied and posted a study (see Cleary et al., 2018) showing that grant funding from the National Institute of Health totalling more than $100 billion contributed to all the 210 new drugs approved by the FDA between 2010 and 2016.

That so many people argued that Gilead in particular, and the pharmaceutical industry in general, receive significant government funds when bringing a drug to market suggests the effectiveness of disseminating this information as part of a ‘war of position’. Consumer advocates have employed this tactic since the establishment of an international patent regime for medicines established over the past couple of decades (Sell & Prakash, 2004).

Health care savings versus the price of life

Another debate questioned whether and how to value health care and human life. Pro-industry arguments centred on the cost of remdesivir relative to other treatments. When Gilead announced its prices for remdesivir in the U.S., the company’s CEO justified the amount stating that it will economise health sector resources. Much of elite opinion reiterated the company’s position:

Never mind that by shortening hospital stays, remdesivir will save insurers, hospitals and patients thousands of dollars per case. Hospitals on average spend $2,500 per in-patient day.

Gilead has said that its drug should help reduce hospital costs by $12,000 a patient.

Beyond the benefit to patients, the financial losses to hospitals as Covid-19 patients disrupt ordinary operations have been devastating. The need to avoid those situations dwarfs paying for even expensive medication.

These views underscore the success of drug companies to maximise pricing new medicines based on reference value of alternative care along with the additional benefits their treatment offers (see Light, 2008). This argument could also be found in the wider discursive field:

I think if you calculate the cost of remdesivir based on value of care it’s cheaper than it should cost. The drug knocks 3 days off a hospital stay. How much is 3 days hospital stay in America worth? Probably more than $3000. So they charge $3000 and it’s a value for that price

If this ends up being true then I guess it works out. If you're in need of this drug, you've already most likely hit your deductible already so your out of pocket cost will likely be $0 regardless. At least it would be on my plan

Within the frame of economising health resources, several comments indirectly justify the drug’s price however expensive; individual patients with insurance would likely have already reached their maximum out-of-pocket limits so should not even be concerned about the price. Since insurance coverage will allegedly cover the cost, individuals should not be concerned. Such a framing, of course, reifies the current health care system in the United States by eliding other possibilities.

While this pro-industry view on pricing resonated among elites and some of the general public, maximalist pricing actions can be constrained by critiques from elites and the public. Many alleged Gilead is abusing its pricing power:

‘An outrageous price for a very modest drug, which taxpayer funding saved from a scrapheap of failures,’ Rep. Lloyd Doggett (D., Texas) said in a written statement.

‘This is not affordable for your person on the street,’ said Rep. Jan Schakowsky (D., Ill.) ‘There's a lot of room for difference when it comes to what Big Pharma says and what we think is reasonable.’

Along with questioning Gilead’s role in developing the drug, these politicians question remdesivir’s differential value of the treatment as well as affordability. This framing also occurs in non-elite discourse:

Hospital Pharmacist here and academic researcher. Not surprised at all. Totally overpriced given the lack of mor[t]ality benefit in the trials.

Yeah, but if your poor and without insurance that 4Gs might as well be 4 billion

Watch insurance premiums shoot up next year. Another reason we need universal health insurance.

Public responses to pricing based on health care savings went even further by critiquing econometric views of human life. Instead, many public commentators articulated an inherent value and dignity of life beyond quantifiable measures.

The bulk of society say ‘Human life is priceless and should be saved at any cost!

This is why for profit medicine is insane. How do you even calculate that value? if my life is on the line it could cost a billion dollars and I'm still going to want it

Granted, drug companies may want to charge more to make a profit that gives them incentive to do research; however, the fact that putting a price on saving a life is outright repulsive in every single common decency of a so called ‘democratic nation’.

In this view, prescription drugs are not like other commodities whose value results from dispassionate market forces. Rather, the fact that essential medicines save lives imbues a powerful counter-hegemonic frame against maximalist pricing, as evidence in other cases such as AIDS drugs, cancer treatments, etc.

To the degree that life-saving medicines are different from other market goods draw additional condemnation about the practice of profit-making expressed by the public.

They charge an immensely high price for the drug, only to make profits faster, which in all due respect, is disgusting.

Let the gouging begin

These statements define Gilead’s pricing of remdesivir as exorbitant as patients are not free to decline the medication. In contrast to pro-corporate views allowing Gilead to capture all the social gains from the treatment, profit-making becomes a stigmatising practice, especially given large mark-ups.

That drugs save lives suggests pricing should not be based on health care savings but instead calculated on the cost of production:

The cost should be based on the cost of making not it's effectiveness. This could save countless lives, no way should this drug cost over $100. It's unethical.

What is the manufacture cost of this? If they are charging 3 K for a drug that costs 10 dollars to make … we have a problem here. No drug shold have a 3000% markup. Period

In defense of Gilead’s price, one commenter rebutted: ‘I'm a chemist, this drug is extremely difficult and costly to make. Honestly, $3k isn't that much for hard it is to make’. However, a cost study estimated that remdesivir could be produced as low as $9 per treatment course (Hill et al., 2020). In previous episodes such as the pricing of antiretrovirals worldwide and of ciproflaxen during the U.S. anthrax scares, revelations of cheaper alternatives and manufacturing costs has resonated with the public and forced drug companies to reduce prices.

Comparing health systems and access across countries

The discursive field involved discussion over the health system in general. Some pro-corporate public comments attempted to downplay the impact of prices arguing either that private insurance will assume the entire cost of treatment or that prices are comparable to those paid in other countries:

The insurance companies aren’t paying 540 per vial on insulin either. The price they pay, which is not the sticker price is private information negotiated between insurance companies and prescription group. For drugs Americans pay similar price per molecule to countries like Germany and Japan, we simply consume more and have a preference for name brand drugs.

This quotation suggests that the U.S. health system is not worse than that of peer nations, since individuals ultimately pay similar rates. The perspective denies any claims that domestic drug prices are high and that criticism of the U.S. care system lacks merit, despite the consensus concerning the high drug prices in the U.S. (Kang et al., 2020) that feeds the anti-corporate critiques of Gilead’s price for remdesivir.

In fact, several anti-corporate commentators cast the U.S. healthcare system in a negative light and extolled the benefits and savings found in other countries. In one instance, an individual expressed that they were ‘so happy to be in a country with socialised medicine’.

Most other countries seem to manage drug research without the need to bankrupt everyone. I suspect ‘research costs’ are ridiculously inflated in the USA system, in the same way that medical bills charges are, to keep the profit flowing at every stage in the process.

There is no equivalence in our health care systems besides the standard of care- I think many Americans would like to believe they're not THAT worse off, but in reality you're not even close. Even for Americans with this mythical ‘really good insurance’, I bet they've still paid more out of pocket costs for regular run of the mill stuff than I have in my lifetime as an uninsured Australian.

When Canada negotiates for a drug, they get a good price.

These comments reflect the increasing awareness of differential prices of prescription drugs and cost of other health services around the world. This observation is tied to a critique of the U.S. healthcare system in general. Some statements assert that policy action could achieve significant savings instead of ensuring profits. One elite comment emphasised this fact:

The Trump administration has been critical of other rich countries paying less for prescription drugs than the U.S., and has threatened to implement regulations that would tie U.S. government reimbursement to prices paid abroad.

In August 2020, the Trump administration signed an executive order allowing Medicare to use international reference prices when purchasing prescription drugs. While the industry trade group PhRMA denounced the order, questions remained about its implementation and likely court challenges (Stolberg, 2020). In fact, many other countries already engage in international reference pricing, yet the industry’s larger concern is if the U.S. government were to negotiate one price for all prescription drug purchases across federal programmes.

The virtues and evils of both capitalism and socialism

Finally, the discursive field contains competing claims about the economic system that organises the U.S. health care. A common theme that came from the data emphasised the alleged problems with government interventions in the market, on the one hand, and problems associated with a system geared towards profits, on the other. A WSJ editorial best articulates elite discourse in defense of capitalism and against government interventions:

The threat of drug price controls is bad enough and would result in Americans waiting longer for new treatments, as patients in socialized health systems do now. Many drugs evolve in part from basic research funded by government. If progressives have their way, every vaccine and drug maker could have to hand over its intellectual property on demand to the government. This would kill the innovation that is saving the lives of Covid patients. Better pray the pandemic subsides before these Democrats control the government.

This author moves from justifying the actions of Gilead to justifying the existence of private property. Many of the public’s comments reiterated themes that fall into this category about how money allows the economy to function, incentives lead to important discoveries and defending ‘free’ markets:

People seem to be unaware that literally ANYTHING has a price in the system we are in. Money makes the world go around

… because of the profit motive most people in novel drug discovery are incentivized to go work for the drug companies. It’s rare to find a pharmacologist or biochemist doing serious drug design that wants to stay in academia. They’d be stupid to.

I don't think the theory of free market medicine is completely evil.

These statements all draw on the frames of individual financial interests and the free market. In effect, these discourses attempt to de-stigmatise critiques against a system under-girding high-priced medicines by naturalising its existence and downplaying negative effects.

Relatedly, others attempt to highlight the problem of government intervention:

For better or worse, a universal healthcare system would probably not give patients this drug en masse or other fancy new cancer drugs. The UK’s NHS has a panel to decide who gets what drug and will often deny expensive ones to patients

The federal government has over-regulated the healthcare industry in favor of the large existing hospital orgs, insurance companies, and big pharma. I left my pharma job after 5 years because it was obviously a tainted industry. The answer is less government, not the government picking winners.

The first post refers to the United Kingdom’s National Institute for Health and Care Excellence – a government agency that conducts cost–benefit analyses to determine what health technologies its publicly funded National Health Service will pay for their distribution. The second accepts the premise of the problems associated with the health industries but casts blame not on capitalism per se on the U.S. government.

In contrast to defences of the private sector, there were also many condemnations of the current economic system and institutions, like the statement ‘Capitalism is the worst’. While there were few explicit references to capitalism per se, many posts specifically mention ‘profit’ as the root of many of the problems in the U.S. healthcare system. These were not opinions expressed by elites, but rather from the general public:

Our for-profit healthcare system. Everything about it is wrong.

Seriously, I think everyone is aware that human life has a price in our current system. That's not some little known fact. We just think that's wrong, and a system that allows for that is disgusting and should be replaced or changed.

You guys should be rioting about your shitty over priced healthcare, honestly. Pretty sure that kills more people than US cops

These comments locate the problem not with an individual corporation, but with the entire economic system.

Lastly, there were several public comments that were categorized into an ‘other’ category. Statements comprised debates about the science behind remdesivir’s efficacy, allegations of the corrupt institutions and individuals, including specific people in power or have been in power, and the relationships between lobbyists and the government. Several of these comments underscore a wider form of distrust in mainstream institutions pervasive throughout society (Gauchat, 2012), particularly the alleged corrosive effect of money on the political system and government agencies. While some of these comments border on conspiracy regarding the use of hydroxychloroquine as a treatment, others dismissed these claims by marshalling other scientific discourses and referencing the off-patent drug dexamethasone.

The discursive context of pharmaceutical pricing contests

This qualitative content analysis reveals that pharmaceutical pricing remains an emotionally charged and highly contested issue in the public sphere. While elite voices produced more online content defending the pharmaceutical industry and the U.S. healthcare system in general, the general public generated more comments critical of Gilead’s pricing actions and of the institutional supports of Big Pharma. Pharmaceutical corporations, then, do not enjoy hegemonic dominance as both specific and general counter-hegemonic framings are readily found in the discursive field that surrounds their actions. This study thus aligns with surveys demonstrating that pharmaceutical corporations remain one of the most stigmatised industries in eyes of U.S. respondents (McCarthy, 2019) but goes beyond polls by identifying specific issues of contention. Moreover, public statements in favour and against drug companies coincide with but also go beyond many of the elite frames. This study did not examine whether there was a direct ‘top-down’ effect of elite discourse on the public, yet there were many instances in which readers copied and pasted portions of articles into the comments sections. Still, the present study offers insight into the discursive context that enables and constrains corporate pricing practices.

We found both support for and opposition to Gilead’s pricing of remdesivir in the discursive field. For those generally supportive of the company’s actions, the most common defence emphasises the amount of resources the company invested to research and develop the drug. Pro-corporate views in this study included detailed justifications based on the cost of capital, large up-front investments, failure rates and references to peer-reviewed studies. Emphasising private sector efforts and resources in R&D is a common theme found in other qualitative content analyses about access to medicines in Brazil (Flynn & Silva, 2020) or in Canada (Esmail et al., 2010). Critics attacked this claim by arguing that government support and resources played a pivotal role in developing the drug. In several instances, the general public cited reports disseminated by consumer advocates that highlight the role of public resources in drug development. Forcing drug companies to disclose R&D costs, status of patents and their prices in other countries, as a proposed resolution at the WHO in 2019 and a regulation passed in Italy in August 2020, will likely make a significant contribution to this effort. Similarly, corporate supporters who can marshal studies estimating exorbitant R&D drug costs in the billions still retain the de facto hegemonic view, especially in elite circles. Overall, debates about R&D costs remain an important crucible.

One of the most common anti-Gilead frames, also found in other studies, condemned the company for profiting of human life. Continued efforts to raise issues of affordability to the detriment of saving lives, especially as they compare to other countries, are likely to continue mobilising outrage. While other studies focused on countries with fewer resources than the U.S., they also emphasised the connection between prices and saving lives (Esmail et al., 2010; Flynn & Silva, 2020). Needless to say, elites and some of the public embraced the company’s view that pricing remdesivir in relation to days in the hospital are justified. Further enabling its pricing policies were claims that there are no out-of-pocket expenses because of assertions that insurance will assume the cost. Still, others have contended that premiums will subsequently increase.

Two frames that rarely appeared in our study are human rights and intellectual property. The struggle to access medicines across the world has largely been couched in human rights language (Gruskin & Raad, 2010; Hogerzeil, 2006). The lack of the right to health in the United States potentially explains this omission in the present study, but also elites elsewhere compared to the public have often employed a human rights discourse to justify policies to regulate prices. The online discussion also rarely mentioned Gilead’s patenting of remdesivir due to the fact that news articles about price never mentioned this topic apart from the U.S. government’s role in developing the drug. In contrast, advocacy groups have spearheaded campaigns pressuring governments to issue compulsory licenses and allow for more generic competition regarding HIV/AIDS and Hepatitis C (Flynn & Silva, 2020; Owen, 2014).

One theme missing in this qualitative content analysis concerns alternative policies and proposals for researching, developing and producing essential medicines. Hegemony operates by marginalising different alternative approaches for achieving social and economic objectives. In other words, the for-profit system for pharmaceutical innovation and production appears as the only means for addressing public health needs. Despite extensive critiques about capitalist health care, online debates never considered specific alternatives to the institutional structure of corporate-based medicines. This lacuna suggests more work is needed to disseminate different organisational structures to the public that better achieve global health needs. Already important work has highlighted the role of public or state-owned labs for producing anti-retroviral medicines in Brazil (Flynn, 2015), the non-profit Drugs for Neglected Diseases Initiative and the Mario Negri Institute that invert the profit model in order to maximise public health gains (Light, 2020; Light & Maturo, 2015).

Conclusion

Access to medicines, especially during a pandemic, remains a highly contested discursive field. This study revealed the hegemonic and counter-hegemonic discourses related to the price of one of the few treatments used against COVID-19. Various limitations include the bias of using a sample of elite editorials and op-eds from a single U.S. newspaper and public comments available on one website and the lack of information about possible financial ties that may prejudice commentators. Further research that can analyse today’s event in historical perspective will need to evaluate how ideas, strategies and political opportunities result in policy outcomes, similar to studies of the genesis and evolution of access to medicines campaigns (Owen, 2014; Sell & Prakash, 2004). For example, drug companies may simply disavow public relations efforts and instead focus on lobbying initiatives (Stavinoha, 2016). Similarly, more work is needed to explore the public acceptance of alternative approaches to research, develop and distribute essential medicines.

Acknowledgements

An earlier version of this research was presented at the Global Congress on Intellectual Property and the Public Interest: Intellectual Property, the Public Interest and Covid-19. October 6, 2020.

Disclosure statement

No potential conflict of interest was reported by the author(s).