Pharmaceutical lobbying and pandemic stockpiling: A feeling of déjà vu in the Nordic countries and why the sociological perspective is crucial to understand COVID-19

The novel coronavirus SARS-CoV-2 (COVID-19) has spread globally in a short period of time and quickly developed into a pandemic. In connection with its progress, entire cities and countries have been closed down, people are quarantined, and infrastructure and trade have been suspended. As this is a new virus, no vaccine or antiviral drugs are available, but instead non-medical measures such as social distancing may be used to reduce the spread. The Nordic countries, which are known for their similar welfare systems, have chosen pandemic strategies without coordinating with their neighbours. Over one night, Denmark closed the bridge to Sweden and shut down its society, while Sweden keeps as much open as possible and recommends its residents to comply with general advice on reducing the spread. Notably, this is the second time in a short time where Denmark and Sweden diverge in their pandemic response. In 2009, during the H1N1 (swine flu) outbreak, Denmark only vaccinated risk-groups whereas Sweden pursued a mass vaccination strategy. In a previous research project, we compared Sweden’s and Denmark’s contrasting pandemic response focusing on pharmaceutical interventions in terms of vaccination and antivirals. The pressing need to find a solution to the COVID-19 pandemic means that risks and shortcuts may have to be taken in order to come up with a vaccine with apparent risks to individual health. We can therefore see the current pandemic as an opportunity to expand sociological research, since Nordic cooperation once again is uncoordinated, despite signals and agreements of otherwise, and different drugs are fast tracked and already tested in human trials.


Introduction
The novel coronavirus SARS-CoV-2 (COVID-19) has spread globally in a short period of time and quickly developed into a pandemic. In connection with its progress, entire cities and countries closed down to reduce the spread. A key feature of this pandemic response is that individual countries have chosen their own strategies without coordinating with their neighbours, and this is also true for the Nordic countries despite existing pan-Nordic crisis management. While Sweden has stood almost alone in avoiding a lockdown and instead has opted to rely on voluntary, trust-based measures to stem the spread of the virus, Denmark together with Norway and Finland were among the first European states to impose lockdowns, despite their public health experts initially advising against it.
Denmark, for example, closed its border to Sweden over night without discussion with its neighbour with whom it shares a commuter bridge. This is a bit puzzling, since the Nordic region recently launched new initiatives to enhance research collaboration and prepare for any future pandemic in light of past experiences (Nordic Co-operation, 2020; Nordic Council, 2019).

Déjà vu
Notably, this is the second time in a short time where Denmark and Sweden diverge in their pandemic response. In 2009, during the H1N1 (swine flu) outbreak, Denmark only vaccinated risk-groups whereas Sweden pursued mass vaccination. In a previous research project, we compared Sweden's and Denmark's contrasting pandemic response focusing on pharmaceutical interventions in terms of vaccination (Mulinari and Vilhelmsson, 2020) and antiviral strategies (Vilhelmsson and Mulinari, 2018). Now, during the current COVID-19 pandemic, the two neighbours once again arrive at different conclusions about how to mitigate the spread of a novel virus. However, a key question is whether the lack of coordination between countries will persist into the next phase of pandemic response, when vaccines and antivirals become available for large-scale use. A persistent lack of coordination would be highly unfortunate because it would allow pharmaceutical companies to, once again, dictate the rules on a seller's market for vaccines and antivirals.
The pressing need to find a solution to the COVID-19 pandemic means that risks and shortcuts may have to be taken in order to come up with a vaccine and to find already available medicines for treatment, which poses apparent risks to individual health. In addition, efforts by industry to influence country procurement and use of public health drugs are problematic due to the high health and financial stakes and the associated risk that commercial interests will bias decisions (Mulinari, 2016). Furthermore, should public perception be that commercial pressures underpin decisions, trust in public health institutions and policies could be undermined.

Pharmaceuticalisation
Within sociology such concerns have often been linked to broader debates about pharmaceuticalisation, where one main focus area has been the power of diverse social actors to drive or block pharmaceutical uptake (Abraham, 2010). Pharmaceutical companies have long been criticised for lobbying to promote drugs that provide limited clinical gains (Light and Lexchin, 2012) and are not cost-effective (Van de Vooren et al., 2013). Little is known, however, about how pharmaceutical companies lobby authorities or experts responsible for recommending procurement or deployment of public health drugs such as vaccines and antivirals. Nevertheless, companies do engage in high-level lobbying to secure lucrative deals with countries or subnational entities.
A particularly relevant case in point is the global stockpiling of Roche's antiviral drug Tamiflu (oseltamivir) prior to the H1N1 pandemic. Claims by Roche that the drug reduced hospitalisations and serious complications of flu were a key factor underlying the stockpiling decisions. However, in the scientific (Jefferson et al., 2014) and public debates that took place in the aftermath of the H1N1 pandemic, critics accused governments and public institutions of having allowed themselves to be misled by the drug manufacturer into stockpiling a drug with limited efficacy.
In our first study of the H1N1 pandemic (Vilhelmsson and Mulinari, 2018) we identified how Roche lobbied to get countries to stockpile Tamiflu by urging Nordic politicians to sign procurement agreements for Tamiflu claiming that it would be delivered on a "first-come, first-served basis". Roche also "toured" the Nordic countries in the years before the pandemic, repeating this argument to ratchet up volumes of antiviral stockpiles. After one country had bought a certain amount, Roche used it as an argument to push other countries and vice versa. This highlights risks posed by pharmaceutical industry lobbying, and the arguments and tactics deployed by Roche in 2009 are likely to be repeated whenever many countries are negotiating drug procurements in a monopolistic market. We are therefore worried when we see a similar scenario emerging with Gilead's antiviral drug remdesivir (sold under the brand name Veklury) that is being fast-tracked and approved for use in combatting the COVID-19 virus, and where one can expect fierce competition between countries and great pressures on governments to secure procurements.
In another study, we built on Lukes' (1974) three-dimensional view of power to explore the 2009 pandemic vaccination strategies in Sweden and Denmark. We argued that complex events such as pandemic vaccination need to be studied from a broader perspective that considers both overt and subtler, more distal power structures and strategies deployed by various actors that do not necessarily counterbalance one another. Because very few companies had developed pandemic vaccines, it became a "seller's market", similar to what happened with Tamiflu, where the total ordered volume of vaccine determined both how early the first shipment would arrive and the weekly allocated volume. These contractual arrangements created incentives for over-dimensioning orders.
We can therefore see the current COVID-19 pandemic as an opportunity to expand sociological research on pandemic response and pharmaceuticals. Some critics are worried that remdesivir will be touted as a miracle cure for COVID-19, despite limited clinical evidence, very much like Tamiflu, and that countries will be competing to secure and deploy pandemic drugs that have uncertain benefits and risks. In this context, a critical sociological perspective is needed to identify and raise awareness about the power structures and strategies that influence procurement, stockpiling and deployment of pandemic vaccines and antivirals by countries around the world.