Vaccines and great, and you should get yours. But for almost two years now, alongside the showy and ultimately successful hunt for vaccines that fight Covid-19, scientists have also been looking for drugs to treat people who were already sick. That hasn’t gone quite as well: a scientific quest tangled up in hundreds of studies too small to give real answers, then sidetracked by hype over the antimalarial hydroxychloroquine and then the antiparasitic ivermectin. Those didn’t work. But the research continued—and in the past few weeks, it seems to have paid off.
First, in early October, the transnational pharmaceutical company Merck and a biotech company called Ridgeback announced that molnupiravir, a decades-old antiviral drug invented at Emory University, reduced the risk of hospitalizations and deaths in people with Covid-19 by a respectable 50 percent. Then, in early November, the equally transnational pharmaceutical company Pfizer (you might remember it from its mRNA-based Covid vaccine) announced that its purpose-built antiviral Paxlovid likewise reduced the hospital-and-death risk in high-risk Covid patients by a whopping 89 percent.
That’s a win, right? Covid vaccines are finicky, hard to manufacture, and hard to distribute because of, in the case of the ones based on mRNA, a snowflake-like need for ultracold freezers. The steroid dexamethasone is for the severely ill. Monoclonal antibodies have to be administered early to work, and, like the antiviral drug remdesivir, they’re expensive, and both require hospital visits for intravenous infusion. But molnupiravir and Paxlovid are “small-molecule” drugs, easier to make, more stable in storage and distribution, and—this is the big one—they’re just pills. You pop ’em. On a planet ravaged by a pandemic virus, with effective vaccines unavailable in most places, easy-to-use, relatively cheap drugs could help beat the disease. “They’re game-changing in the sense that they’re both pills and therefore relatively easy to take,” says Charles Gore, executive director of the Medicines Patent Pool, a UN-supported organization that sets up international licensing agreements for drugs. “You don’t have to lie down to get an infusion, or walk 150 miles to get to a hospital.”
That’s convenient. And both Merck and Pfizer have also announced extensive licensing agreements with generic drugmakers and tiered pricing for lower-income countries, which is good for places that haven’t been able to afford the vaccines that North America and Europe have been hoarding. “I think the combination of these drugs and vaccines will really make a difference,” says Jayasree Iyer, CEO of the Access to Medicine Foundation, which works on getting critical drugs into lower-income countries. Vaccine makers know they have to do the same kind of technology transfer and licensing agreements for those, Iyer says, “but that’s going to take longer, and the immediate need now has an immediate drug.”
Schaper says the company will have 3 million courses of treatment ready to deploy to low- and middle-income countries as soon as approval comes, and then international generics makers will be able to make medicine for more than 100 countries. Molnupiravir is already approved in the United Kingdom, and the US government has agreed to buy 1.4 million courses of treatment. “Pricing indications, from some academic work on the Merck drug, suggest that it could be around $20 for the five-day course, falling to $10 if they use a process that the Gates Foundation has funded, which optimized production,”
Pfizer, on the other hand, has only just started making pills, but the company also has an agreement with the Medicines Patent Pool. Its Paxlovid blocks an enzyme that the SARS-CoV-2 virus uses to cut big chunks of protein into the sizes and shapes the virus needs to reproduce itself—a “protease inhibitor” like the drugs that were instrumental in the fight against HIV and AIDS. In Paxlovid, that protease inhibitor comes with another drug, ritonavir, that keeps a person’s liver from breaking down the protease inhibitor. A Pfizer spokesperson declined to make anyone from the company available for an interview, but the press release in which Pfizer announced its early trial results also quoted CEO Albert Bourla calling the drug “a real game changer,” for what that’s worth.
According to Pfizer’s spokesperson, the company expects to be able to make 120,000 full courses of the drug before the end of the year, and 50 million courses a year after that. The license deals the company has made via the MPP guarantee tiered pricing to 95 countries—more than half the humans on Earth. And Pfizer has said generic drugmakers in low-income countries need never pay them royalties—in fact, the company won’t collect royalties from anyone until the World Health Organization says the pandemic is over.