Communia

This year marks the 100th anniversary of the discovery and purification of insulin, a natural hormone crucial for treating the growing epidemic of diabetes and on which, in theory, there has been no patent attached for decades. However, the world's insulin production is still monopolized by a handful of companies in Europe and the U.S., which sell it at astronomical prices. The WHO has described this situation as a "catastrophic moral failure" and it certainly is, but how did this happen, and more importantly, how do we get out of it?

A fully concentrated global production

World insulin imports and exports

World insulin production is concentrated in just 10 countries (which account for 98-99% of the profits), but its distribution is somewhat complicated, with some countries such as the USA producing almost no insulin for export, while much of the output moves between these same capital-rich countries.

In reality, most of the world's countries depend on exports from just three European countries: France, Denmark and Germany. In addition, 60 countries, mostly semi-colonial countries, import insulin from a single European country, multiplying the fragility of their public health.

The fact that productive capacity is monopolized in a few countries with highly concentrated capital has immediate and infamous consequences for worldwide access to insulin. For much of the population and workers in low-income countries, insulin - on which they depend for survival - is at near-impossible prices.

On average worldwide, insulin analogues (which are the only ones available in many places), cost 7 to 10 working days' wages. In places like Sri Lanka they can cost 64 working days' wages with a median of 28. But one need not go as far as countries with weaker national capitals, in the USA and Europe insulin is inaccessible to many working families and this situation condemns large numbers of people to a painful and premature death.

Pharmaceutical companies artificially create scarcity by recycling patents...

Insulin patents per pharmaceutical company

The discoverers of insulin patented it in 1923 facing the opposition of much of the rest of the research community. The team defended itself on the grounds that:

When the details of the preparation method are published, anyone would be free to prepare the extract, but no one could secure a profitable monopoly

Today, the sequence of insulin and its production methods are well known and production does not require all that much technical complexity (either insulin produced from animal pancreatic extracts or with recombinant DNA), but there is virtually no generic insulin.

In the U.S., other generic drugs can cost 100 times less than insulin (4 dollars versus 400). This is because large pharmaceutical conglomerates have followed the strategy of continually renewing their control over insulin intellectual property while turning the insulin market into a monopoly of no interest to generic-producing companies.

Lilly and then others such as Denmark's Novo and Nordisk (now merged) began a race of licensable tweaks, from metal complexes which slowed the effect of insulin (better mimicking the natural rate of secretion by the pancreas) to genetic sequence modifications and the production of large "biosimilar" molecules.

This has allowed about three companies to continually renew patents and, with the collusion of quite a few health systems refusing to prescribe "old" versions of insulin, has meant that no generic company is willing to risk investing in an uncertain market in which it has no penetration beforehand.

This is a common practice among large pharmaceutical conglomerates. For instance, Pfizer re-patented a version of its anti-epileptic drug Gabapentin containing marginal improvements when the patent for it was running out. This extended its grip on drug production, but whether the new drug is safer or more effective than the preceding one is unclear.

...and at the expense of hundreds of millions of patients

Global evolution of the type I diabetes epidemic

Today we are in the midst of a global diabetes epidemic, in 2017 there were already 425 million patients and this figure is projected to rise to at least 629 million by 2045, a rise of no less than 48%.

Although some stereotypes might lead one to think so, this is not really a disease specific to high GDP countries, in fact 77% of patients are found in middle- and low-income countries. The same countries in which the vast majority of the population cannot afford insulin prices.

The transformation of the food industry and global production chains to try to capture as much investment and capital as possible is responsible for much of this epidemic through metabolic syndrome.

Read also: What Covid reveals about agriculture and food, 3/31/2020. The health of the economy parasitizes the health of workers and society as a whole, 5/20/2021

But this only partly explains the rise of type II diabetes, due to insulin resistance by bodily tissues. The fact is that Type I diabetes, which is autoimmune in origin, is on the rise as well, and the potential causes - from pollutants, infections or diet - are still largely speculative.

Diabetes is not a minor disease. Excessive blood glucose leads to out-of-control blood glucose reactions with components of the retinal "scaffolding" and other proteins leading to progressive blindness as well as peripheral nerve degeneration. In addition, lack of insulin signaling in the circulatory system leads to amputations, renal failure - it is in fact the number one cause of renal failure - and death.

The death sentence of millions of people who cannot afford what is literally a natural substance is indeed a "catastrophic moral failure" and a completely artificial one. Artificial and caused by a social system which enforces scarcity to further exploit billions of people.

In the U.S. it is often argued that insulin "biosimilars" and the relative opening of the market to new companies will "solve the problem" without disturbing capital accumulation. This supposedly automatic path has been failing miserably for a century as a way to lower prices, however.

From what has already happened in different countries with other biosimilars as well as other products, we now know that the price reduction will clearly be insufficient to allow universal access - probably around 20% - and will still leave most of the world without access to insulin.

There is no reason to keep accepting this murderous imposition of scarcity, when not only are the survival needs of hundreds of millions of people not being met, but the production of and access to something that is relatively simple to produce is being legally and economically prevented.

This is one more expression of the ever-increasing contradiction between human development on the one hand and economic growth (=accumulation) on the other, characteristic of a decadent mode of production like today's capitalism. Precisely because it is neither technical nor scientific problems, but social relations which cause this horror, we must not accept it with patience or fatalism. It will not end with the absence of insulin in research laboratories, but by imposing the primacy of human needs over the urges of capital... something that it is up to us workers to make happen.