Behind the French controversy over the medical treatment of Covid-19: The role of the drug industry

With nearly US $1200 billion in sales in 2019, a threefold increase since the beginning of the 21st century, the pharmaceutical industry has become one of the largest industrial sectors in the world and perhaps the most profitable of all over the last 30 years (Abecassis and Coutinet, 2018; Observatoire Français des Multinationales, 2018). The large pharmaceutical groups that have formed over the last few decades are now competing with the oil industry, banking groups, GAFA (Google, Amazon, Facebook, Apple), the luxury goods industry, the automobile industry and cigarette manufacturers. They are among the multinationals that dominate the world and impose their interests upon it. They develop the same profit maximization strategies as most of these multinationals (takeovers, redundancies in the countries of origin, relocation to poor countries, price gouging, tax evasion, intense lobbying, use of public aid for their benefit, etc.).

The world drug market is dominated mainly by four countries: the United States (Pfizer, Merck, Eli Lilly, AbbVie, Amgen, Gilead Sciences, Johnson & Johnson), Switzerland (Novartis, Roche), France (Sanofi) and Great Britain (GlaxoSmithKline, AstraZeneca). The bosses of these firms are among the best paid in the world (for example, €10 million for the Sanofi boss in 2017; see Petitjean, 2018). Listed on the stock exchange, they are strongly involved in financial market developments and the dividends they pay out to their shareholders are among the highest in the world (nearly $1 trillion in profits over the last 10 years). They have therefore become a central player in the new financial capitalism dominating the planet (Montalban, 2011).

These very large groups not only dominate the global drug market, but are also increasingly influencing medical research. Clinical trials are financed and carried out overwhelmingly by them, sometimes at the request of national agencies such as the Food and Drug Administration in the USA. It is in this political-industrial movement that evidence-based medicine and its statistical methods of randomization have been established, giving the illusion of a mathematical demonstration that cannot be falsified (Capraş et al., 2019).¹ The principle is to substitute statistical calculation for clinical experience, mathematical demonstration for medical practice. An increasing number of doctor-researchers can thus multiply publications on diseases and drugs, even when they no longer see patients or practise medicine. Laboratories pay them for studies to test drugs. They determine the protocols and even pay several thousand euros per patient included in their studies (Bégaud, 2020). They also organize ‘boards’ and other ‘strategic meetings’ in which physicians are involved in determining laboratory projects and for which the same physicians are frequently paid €1500 a day. The laboratories finance travel and all hotel and catering expenses of these physician-researchers (several thousand euros each time) so that they can present their results at international symposia, the overall organization of which is itself largely financed by the laboratories. In some cases, industrial groups go so far as to carry out the studies themselves in their laboratories and then propose to more or less renowned university doctors that they sign their names to them. Over the last 30 years, this so-called ‘ghost-writing’ has given rise to numerous frauds and practices that are dangerous to public health (see, for example, Lacasse and Leo, 2010; McHenry, 2012).

Contrary to popular belief, it is not only second-rate authors and journals, but also the world’s most prestigious scientific journals that are implicated in this corruption of science. For example, in 2009, Dr Marcia Angell, the former publisher of the American New England Journal of Medicine (NEJM) wrote:

And in 2015, the scientific editor of the equally prestigious British medical journal The Lancet wrote:

In France, a few years ago, the collective ‘Regards citoyens’ (created in 2009)² carefully examined the government website ‘Transparence Santé’ created after the Mediator scandal.³ They unearthed the existence of 2.5 million gifts made between January 2012 and June 2014 by laboratories, mainly to doctors, for a total amount of approximately €245 million. Let us be clear: this is an organized system of influence peddling (Light et al., 2013).

For the pharmaceutical industry, the control of scientific production in the world of medical research is only one element of their overall information control strategy. Incredible as it may seem, this strategy is first expressed in the pharmaceutical companies’ stranglehold on the continuing education that is compulsory for doctors. This long-standing practice was made official in France in November 2006, when the Minister of Health at the time (Xavier Bertrand) signed an agreement and a code of good practice with the union of pharmaceutical companies (Les Entreprises du Médicament, LEEM). This agreement was strongly denounced at the time by Form Indep, an association fighting against ‘interference by commercial interests or administrative injunctions in medical training and information, as well as in the healthcare chain’ (Form Indep, 2006). This strategy naturally extends into a very intense lobbying campaign aimed at elected representatives and national and international government agencies regulating public health (Horel, 2018). In France, the High Authority for the Transparency of Public Life (HATVP) lists these lobbying activities. It reports, for example, that the LEEM, representing 266 pharmaceutical laboratories or companies from around the world, spent nearly €1 million on official lobbying in France in 2018.⁴ In 2019, the Gilead Sciences group employed four people and spent between €400,000 and €500,000 on its lobbying activities with French parliamentarians alone. And, this is only a small part of Gilead’s overall strategy of influence. In total, Gilead is estimated to have spent $65 million over the last seven years to establish its influence in France, both with practitioners and institutions (Verhaeghe, 2020a). Thanks to the Euro for Docs website,⁵ the distribution of these tens of millions of euros spent by the laboratory can be examined much more easily. Unsurprisingly, the bulk of the funds went to (1) doctors (most of whom expressed opposition to Raoult in the media), (2) organizations for the initial or continuing training of health professionals, (3) the media, (4) academies, foundations, learned societies and advisory bodies.

What is Gilead? This American group employs nearly 12,000 people and had sales of $22.5 billion in 2019.⁶ Its shareholders include some of the largest US investment funds. The first is Vanguard Group, a direct competitor of Black Rock (the world’s largest asset manager and one of the largest shareholders in the CAC40, a benchmark French stock market index). Vanguard is also the largest shareholder of Apple and owns 5% of Amazon (and has invested in a number of large French companies). The same goes for Gilead’s second largest shareholder, Capital Research and Management. So here we are at the heart of today’s financial capitalism and its American domination.

Gilead offers an antiviral drug to treat Covid: Remdesivir. The laboratory has been working on it since the Ebola virus epidemic that ravaged West Africa during 2014 and 2015. Faced with the current pandemic, the challenge for Gilead is to convince people that its new molecule is much more effective than hydroxychloroquine (a very old antimalarial drug) and azithromycin (a bactericidal antibiotic), which is Raoult’s preferred protocol. However, there is one major difference: hydroxychloroquine has long since fallen into the public domain, so any manufacturer can make generics of it and sell them all over the world (this is what the generic giant Mylan has already announced; see Viudez, 2020). In France, a box of Plaquenil (hydroxychloroquine) sold at around €2.20 in January 2020. The price of Remdesivir is unknown at this time, but the drug is patented. It is only known that the basic production of the molecule it uses costs about 12 times more than that of hydroxychloroquine (Hill et al., 2020). It is also a much more expensive intravenous injection and a longer treatment. As a result, the Institute for Clinical and Economic Review (ICER) estimates the break-even point for this drug is about $4,500 per treatment (Liu, 2020). Enough to earn billions more with Covid, especially since Gilead is known to practise greedy price gouging for maximum enrichment.

Just over five years ago (November 2014) Gilead launched a drug called Sovaldi on the hepatitis C market. And while its manufacturing cost would be between €100 and €200, Sovaldi would cost from at least 1 to 100 times more, depending on the wealth of the countries with which the laboratory was negotiating. In France, the treatment will be sold by Gilead for up to €42,000 per patient. Finally, in less than three years, it will have cost the French health insurance system more than €700 million. This makes it one of the most expensive drugs in the history of this public insurance system (Gouin, 2017). However, the political and health authorities had plenty of time to think about it before making the purchase. In 2013, the Minister of Health (Marisol Touraine) had commissioned a report on the case from Professor Dhumeaux who had links of interest with Gilead (Pesty, 2015).

In the end, in the space of three years (2014–16), Gilead amassed nearly $44 billion in accumulated net profit – an unexpected windfall that moved this group from 40th to 6th place in the economic ranking of pharmaceutical companies.

The health governance of the Covid crisis is a very complex political-administrative network. It involves bodies directly dependent on the Ministry of Health such as: the High Council for Public Health (HCSP) and the National Public Health Agency (ANSP), independent public authorities such as the High Authority for Health (HAS), public establishments such as the National Agency for the Safety of Medicines and Health Products (ANSM), the National Institute for Health and Medical Research (INSERM), and public interest groups such as the National Cancer Institute. Four sets of players interact in a global regulatory logic marked by New Public Management:

1. professionals (especially doctors);

2. public managers;

3. market players (pharmaceutical companies, insurance companies, etc.);

4. political leaders (Contandriopoulos, 2008; Pierru, 2013).

Given the cumbersome nature of this bureaucracy, in the face of the Covid crisis and the need to make decisions in a hurry, the President of the Republic decided to create a ‘Scientific Council’ (CS-COVID) on 11 March 2020, then a ‘Committee for Analysis, Research and Expertise’ (CARE) on 24 March, to advise the government on health and therapeutic choices. In less than two weeks, the space in which decisions take place has therefore been considerably reduced. And in these small networks (about 10 people in both cases), links of interest can play an even greater role as they are no longer counterbalanced or controlled by other forces.

The influence of pharmaceutical companies is exerted within the working groups and places of expertise set up by the public authorities within public administrations. In one of the main working groups set up to examine the treatment of hepatitis C (mentioned earlier), the citizen vigilance groups were able to show that 12 of the 20 experts gathered had participated on Gilead Sciences’ boards during the period when the recommendations that were to be made to the Minister of Health were being drawn up (Pesty, 2015). One of these key experts was Dr Yazdan Yazdanpanah (Head of the Infectious Diseases Department at Bichat Hospital, Paris), who currently happens to be a member of both CS-COVID and CARE. He is therefore one of the key players in the management of the Covid-19 crisis in France. He was also entrusted with the steering of the clinical trial called Discovery, launched by the government to allegedly decide on the best medical treatment for Covid (Ghaled et al., 2020). His links with Gilead are numerous and important. It can therefore be said that official clinical trials ‘are conducted in France by a man who has received sums of money from the laboratories whose drugs are being tested’ (Verhaeghe, 2020b).

Still on the subject of the hepatitis C case, in 2013 Professor Dhumeaux was entrusted with the report on hepatitis C treatment on the recommendation of Jean-François Delfraissy, then director of the National Agency for Research on AIDS and Viral Hepatitis (ANRS), who also had links with Gilead (Pesty, 2015). But Delfraissy is none other than the current president of the CS-COVID . . .

Yazdanpanah has been at the head of an important French research consortium (REACTing) on infectious diseases together with Delfraissy since 2014. Yazdanpanah is a member of both the Scientific Council and the CARE. And among the personalities involved to varying degrees in the governance of REACTing, there is also a sociologist, an epidemiologist, an expert on infection, a virologist and a medical officer who are all members of CS-COVID. It can therefore be said that this council is in reality almost an annex of REACTing, led by Delfraissy and Yazdanpanah. These two men organized their domination of these two councils by co-opting members of their network.

There is more. Yazdanpanah also heads a large thematic research institute of INSERM where he was appointed in 2017 by the director general of this public research organization, Dr Yves Lévy, who is none other than the husband of former Health Minister Agnès Buzyn, and who were both institutional opponents of Dr Raoult in previous years (Campion, 2020a).

Finally, after being appointed to CS-COVID because he is the most recognized French virologist in the world, Professor Raoult resigned after a few days because of his disagreements with this network. He was replaced by Dr Franck Chauvin, President of the High Council of Public Health (HCSP). This public agency notably houses an important ‘Specialized Commission on Infectious and Emerging Diseases’ whose president, vice-president and a third member all have strong links of interest with Gilead (Campion, 2020b). A few days before Dr Raoult was replaced by Dr Chauvin, the HCSP in turn recommended Gilead’s drug as the ‘only formalized treatment option’ for hospitalized patients (Demarti, 2020).