As I wrote this column, I had a deeply frustrating déjà vu moment. Frustrating because it showed how our industry hasn’t changed much in 46 years, deeply so because the issue – access to medicines – is so important. Let me tell you the story and how we might give it a happier ending.

My déjà vu was triggered by the Access to Medicines Foundation, which reported that, although many pharma companies have programmes to improve access to medicines in low- to middle-income countries, few are comprehensive and their effectiveness is uncertain. In short, we’re a very long way away from making the miracles of pharmaceutical innovation globally accessible. In my book Darwin’s Medicine, I have described this as the ‘beyond reach’ trough.

As I read the report, my memory skipped to a February morning in 1978 in a cold meeting room in Northern England. It was induction training in my first job as a research scientist. The enthusiastic presenter was pointing to a map of all the countries in which our medicines were sold. Perhaps 20 or 30 countries in blue, all Western and developed. Most of the world was white space. When I asked why, she blamed lack of demand, which seemed odd even to my very young and innocent ears.

The same map today would be more blue and less white but, as the new report illustrates, the underlying problem persists. Even if a drug is sold in, say, Nepal or Zimbabwe, it isn’t accessible to most patients. And my teacher would be as wrong today as she was then. The demand is there; it’s the ability to pay that isn’t.

For an industry advocate like me, the persistence of limitations on access is frustrating, especially since this is a problem both for poorer countries and, with advanced therapies, those that are richer. But I’m not just an industry advocate, I’m also an academic who uses evolutionary science to explain how our industry evolves and to help firms manage their own evolution. And Darwinian thinking gives a useful perspective on the ‘beyond reach’ trough.

From a Darwinian perspective, access programmes look at the problem from the wrong end. They make medicines affordable by reducing prices, sometimes to nothing, by cross-subsidies from high-paying customers. This helps a little but, as the report implies, nowhere near enough. The most generous access programmes imaginable can never make drugs that cost a lot to invent fully accessible to the poor, whether they live in Sudan or Switzerland. Fiddling with the purchase price of drugs is necessary but not sufficient. We need to do something about the costs of bringing pharmaceutical innovation to market.

Darwinists like me see hugely expensive pharmaceutical innovation as a trait of current business models. It is a trait that is strongly selected against in low-income habitats, making those models non-viable there. A biological analogy would be poikilotherms (cold-blooded creatures), which struggle to survive in cold habitats. Limited, localised reduction of purchase prices is like providing a warm room for lizards in the Arctic. It isn’t going to solve the wider access issue. Instead, we need an evolutionary leap that slashes innovation costs. The relevant analogy would be the Jurassic evolutionary leap to homeothermy (warm-bloodedness). As I’ve argued in my book New Drugs, Fair Prices, we already know the business model mutation needed to make that leap. We must improve translational science so that the attrition rate in drug development is much less.1 Innovative pharma business models that make that leap will have much lower costs and will be able to extend access far more deeply into the ‘beyond reach’ trough.

So why hasn’t the industry made this leap yet? Fundamental translational science is like common land. It benefits the entire industry, but not a specific firm. Consequently, pharma companies are happy to exploit it and to invest in translational research that is proprietary, such as for a drug with exclusivity. But no one wants to invest in the open access fundamental science. Governments do this but nowhere near enough. There’s an extensive National Institutes of Health wish list for the translational science that needs investment. It’s that tragedy of the commons that is the cause of my déjà vu and why the poor have little immediate hope of wider access to pharmaceutical innovation.

Download a sample chapter of New Drugs, Fair Prices here, or contact brian.smith@pragmedic.com