No one has conducted as granular an analysis of other vaccine candidates. The Moderna vaccine, for instance, is built on three crucial breakthroughs. The first, conceived by scientists at the University of Pennsylvania, enables injected RNA particles to elude the body’s immune system; the second is a minuscule sheath of fat that transports and then releases the RNA; the third is a protein present in the vaccine.

All three breakthroughs were the result of extensive public funding, particularly from the US National Institutes of Health (NIH), which poured $17.2 billion into vaccine technology research between 2000-2019. In fact, the NIH holds the patent for the vaccine protein, which is present in other mRNA vaccines apart from Moderna’s. But Moderna does not pay the NIH a license fee to use the patent, and the NIH has—for unspecified reasons—chosen not to enforce the patent. A new study by New York University researchers estimates the patent could earn the US $1.8 billion in 2021. (AstraZeneca, Moderna, and the NIH did not respond to requests for comment.)

None of these calculations are perfect. Sarai Keestra, a medical anthropologist at the London School of Hygiene & Tropical Medicine and one of Rodger’s co-authors, said that grant amounts provided by many funders mentioned in the ChAdOx literature weren’t publicly available. “And we don’t know how much private money went into this research,” Keestra said.

Similarly, in the post-research phases of drug development, pharma companies invest their own money in trials, licensing, manufacturing, marketing, and distribution. Companies like AstraZeneca or Moderna haven’t revealed how much they spent on these stages in 2020, said Adrián Alonso Ruiz, a health researcher at the Graduate Institute of International and Development Studies in Geneva. Only a few inferences can be drawn. “For instance, Moderna being a small company, it also received funding from the US to expand manufacturing capacity.” Beyond that, though, Ruiz said, “we’re hitting the same wall: a lack of transparency that doesn’t let us account for the entire value of these vaccines.”

What if the state behaved like an investor?

The question of where funds come from is a crucial one. Whenever discussions of drug patents and intellectual property arise—as they have now, for Covid-19 vaccines—pharma companies argue that slackening patent restrictions will be counter-productive. That without the revenues accruing from strict and exclusive patent regimes, companies will have no incentives to develop drugs—and no funds to conduct the research needed. But as the drive to develop Covid-19 vaccines suggests, often companies don’t fund the research needed—certainly not all of it, anyway.

This gives states leverage they ought to use, Ruiz said. “They have the powers of early investors who take risky bets.” Except, unlike venture capitalists, public funders can look not for profit but for other objectives tied to the public good: lower prices in perpetuity, or more equitable access, or wider licensing to boost vaccine supplies.

Bodies like CEPI or the NIH can exert “step-in rights” for drugs they’ve helped fund, compelling firms to make these products more widely or cheaply available. The rights are often found in contract clauses, Ruiz said. They just aren’t enforced, perhaps because the pharma world’s lobbyists are powerful and effective, but also because the structure of the industry is so entrenched it goes unquestioned. We’ve come to believe that this is the only efficient way to get drugs to market, and healthcare is so important that we’re unwilling to try to upgrade the model in bold ways.

Governments fail to re-evaluate their own roles as well, being content with disbursing money and aiding research without looking downstream, past election cycles, when the research pays off. This is a timid ideology of state function, Ruiz suggested. Instead, states should learn to see themselves as “entrepreneurial states.” The NIH, for instance, can demand that companies pay fees to license its patents, so that it can then plow that money back into further research. During crises, where the lion’s share of funding for a treatment has come from public sources—and some of the Covid-19 vaccines are prime examples—governments have even greater moral authority to press these demands. Ruiz said: “Governments need to ask for something in return, the way investors do.”

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