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Eight years after he was first found to be hiking up the price of a drug used to treat AIDS, cancer and malaria by more than 5000%, Martin Shkreli has received his comeuppance: a US court has banned him from ever working in big pharma and ordered him to repay the $US64.6 million he gained from the drug Daraprim when he was CEO of Turing Pharmaceuticals.

Shkreli, who is serving seven years for securities fraud, is reportedly unrepentant, a point not lost on US District Court Judge Denise Cote: “Shkreli’s anticompetitive conduct at the expense of the public health was flagrant and reckless. Barring him from the opportunity to repeat that conduct is nothing if not in the interest of justice.”

But will slugging one of the most egregious exemplars of the drug industry exploitation help restore trust in big pharma? The world has turned to pharmaceutical companies in the pandemic, relying on manufacturers for COVID-19 vaccines, treatments and life-saving interventions for those who develop severe disease. But it hasn’t done much to increase public trust: last year Australia became completely reliant on big pharma for a pathway out of the pandemic, but just 62% of people said they trusted the pharmaceutical industry. In comparison, 75% of Australians said they trusted healthcare.

Globally, trust in pharmaceutical healthcare has stayed the same since 2019, 57%, while trust in biotech healthcare dropped from 64% to 61% across 2019-21.

Do we trust big pharma?

In the 2021 Accenture Health and Life Sciences Experience Survey, only 15% of US respondents reported that they trusted pharmaceutical companies more than before the pandemic.

One US survey found fewer than 70% of respondents had a “favourable” view of Pfizer, Moderna and Johnson & Johnson vaccine manufacturers. Although a Statista survey found 62% of Australians trusted big pharma, just 50% of those in the UK did — compared with 80% of Indian respondents.

Before vaccines became widely available, misinformation and misunderstanding around COVID treatments including hydroxychloroquine and remdesivir didn’t help. In the United States, the drugs were given emergency use authorisation, with former president Donald Trump calling remdesivir a “cure” for the virus, despite no evidence.

Concerns around links to rare blood clots of the AstraZeneca vaccine had a massive impact in Australia, with many of those then eligible for the vaccine opting to wait for Pfizer to arrive, delaying the vaccine rollout. Medical mistrust has fuelled the anti-vaxxer movement abroad.

But as vaccines proved safe and effective and adverse side effects rare, big pharma enjoyed a reputational boost, albeit slight. In the US, a Gallup poll found the pharmaceutical industry was the most poorly regarded out of 25 industries. By 2021, it had moved up slightly to 21st place.

But the starting point was low following decades of overcharging, lawsuits and lobbying — and Shkreli’s ban is just the tip of the iceberg.

Money fuels mistrust

There’s a long history of mistrust in big pharma, especially in marginalised communities. The Tuskegee Study, where the US government allowed 600 Black Americans to go untreated with syphilis to study the effects of the disease, has fuelled generational mistrust. In one survey, 97% of Black HIV-positive Americans endorsed at least one general COVID-19 mistrust belief. 

Then there are high-profile figures like Shkreli and Theranos founder Elizabeth Holmes, ongoing lobbying by big pharma targeting doctors by sponsoring lavish educational events and paying big money for GPs to be guest speakers and sit on advisory boards, and the increasing cost of cancer drugs despite no proof they’re better value or more effective.

A major factor fuelling mistrust is perceived profiteering, University of Sydney pharmaceutical policy research scientist associate professor Barbara Mintzes says.

“One of the things that has eroded public trust directly would be very high prices for specific medicines that are really beyond what health systems can bear,” she said.

And across the pandemic, pharmaceutical companies’ profits have been in the spotlight.

COVID treatment drug molnupiravir is sold by manufacturer Merck to the US for 40 times what it costs to make. Australia has ordered 300,000 doses. And COVID vaccine manufacturer Pfizer was fined $US106 million in 2016 for a 2600% price hike on anti-epilepsy medication. It has also been accused of price gouging after raising the price of its COVID vaccine by more than a quarter in EU supply contracts. 

Pfizer has been criticised by consumer rights group Public Citizen for creating contracts with the US, UK, European Commission, Albania, Brazil, Colombia, Chile, Dominican Republic and Peru which give it the power to block countries from donating their vaccines.

Unlike AstraZeneca, Pfizer and Moderna also won’t share their vaccine “recipe” to allow doses to be manufactured under contract in other countries. It expects to make a US$15 billion profit from vaccine sales across 2021.

There are limited international laws around what drug companies can charge, and there are seven-year patent laws preventing other companies from making generic versions.

In an interview with the Wall Street Journal, Pfizer CEO Albert Bourla said it deserved to make a profit off its vaccine.

“Can you think of someone that would deserve to make money other than someone” saved so many lives, “emptied hospitals”, and saved trillions of dollars by limiting severe disease, he asked.

What can big pharma do? 

Bourla acknowledged there was limited trust in big pharma, and that companies had to work hard to earn it back, but pointed to increased investment in research since he took over the company. 

Lobbying transparency has increased across the past decade. In the US under Obamacare, the Open Payments database requires companies to report every payment to a doctor over $10, including buying them food, drink or paying for their accommodation.

Since 2016 Medicines Australia has asked every member company to list every payment made to a health professional, collating it into a public database. But this reporting is limited: only Medicines Australia members have to list what they’ve spent and it doesn’t cover food and drink. A 2016 study of US doctors found even a single $20 meal paid by an industry representative led to increased prescriptions of a brand-name medication.

Mintzes says there was a lot more companies and regulators could be doing. 

“Countries globally together should be looking at whether the system that we have now right with patent protection is actually meeting the goals of innovation, and also ensure that people have access to the health treatments that they need,” she said. 

International trade agreements for livesaving drugs have been struck before, breaking patent monopoly around AIDS and hepatitis C drugs, making them available at affordable prices around the world. 

Mintzes says companies should also have to show how their brand-name drug compares with existing treatments.

University of Newcastle chair of clinical pharmacology Jennifer Martin — who has sat on a number of Commonwealth, state and New Zealand advisory committees including the Therapeutic Goods Administration advisory committee — says aid-independent fact-checking committees and declaration of interest processes are key to ensuring objective scientific decisions can be made on which drugs are publicly available and to whom.

However, she says, that doesn’t mean committee members are psychologically resistant to the personal concerns of public opinion and persistent pressure, including emails, phone calls and publication of specific clinical scenarios affected by the decision in the media.

“The aim of all lobbying behaviour from industry including indirectly from community and groups affected by the outcomes is really to generate pressure on those people making a decision,” she said.

“But we’ve got to trust that the people appointed by governments to make these decisions, and the processes and checking behind those appointments, are robust enough to stand firm from a lot of the pressures coming from industry.”