One Step Towards Health Equity

Dear Leading Ladies,

Imagine you have a chronic disease that can be easily managed by a medication you cannot afford. If you don’t take the medicine every day, you risk going blind, having your legs amputated, or dying. But you just don’t have the money, so you ration your doses, hoping that some medication is better than none. You are playing a game of roulette you didn’t choose.

One that too many Americans with diabetes are forced to play.

A clinical study published in the Journal of the American Medical Association (JAMA) in 2019, stated that “one in 4 patients at an urban diabetes center reported cost-related insulin underuse and this was associated with poor glycemic control. These results highlight an urgent need to address affordability of insulin.” Moreover, “More than one-third of patients who experienced cost-related underuse did not discuss this with their clinician.” The writers concluded that “Regulators and the medical community need to intervene to ensure that insulin is affordable to patients who need it. At minimum, individual clinicians should screen all patients for cost issues to help them address these challenges.”

A historical perspective

How did we get to the point that a quarter of the people in this country suffering from diabetes lack the means to pay for the full dosage of insulin they require – insulin that increased anywhere from 300 to 1,000% over the past three decades?!?

To understand the problem, we took a look at the history. In the late 19th century, two German researchers discovered that insulin was produced in the pancreas. Then, in 1910, an English researcher concluded that people with diabetes were lacking insulin in their pancreases. His work was followed in 1921 by surgeon Frederick Banting and his assistant Charles Best, who discovered a way to remove insulin from a dog’s pancreas. The next step came when J.B. Collip and John Macleod helped Banting and Best refine and purify the insulin from cows, instead of dogs. (Since then, synthetic insulin has been developed.)

Banting, Best, and Collip were awarded the American patents for insulin which, according to Diabetes.org, they sold to the University of Toronto for $1.00 each. The University of Toronto allowed Eli Lilly to produce insulin in exchange for a one-year distribution monopoly at two cents a unit, a far cry from the out-of-sight prices of today. “Insulin does not belong to me,” Mr. Banting said at the time. “It belongs to the world.”

Illinoisscience.org

Some good news

Last week, Eli Lilly announced that it would reduce the price of its insulin products. Specifically, the company’s news release said, “Eli Lilly and Company (NYSE: LLY) today announced price reductions of 70% for its most commonly prescribed insulins and an expansion of its Insulin Value Program that caps patient out-of-pocket costs at $35 or less per month. Lilly is taking these actions to make it easier to access Lilly insulin and help Americans who may have difficulty navigating a complex healthcare system that may keep them from getting affordable insulin.” In the announcement, David A. Ricks, Lilly’s Chair and CEO said, "While the current healthcare system provides access to insulin for most people with diabetes, it still does not provide affordable insulin for everyone and that needs to change. The aggressive price cuts we're announcing today should make a real difference for Americans with diabetes.”

But here’s the rub. The $35 cap was already in place. Price cuts on some newer Eli Lilly insulin products have not been announced. Sanofi and Novo Nordisk, the other two major manufacturers of insulin products, have not announced any price cuts. And the prices of all insulin products are still more expensive in the US than they are in other countries, according to the New York Times.

The Times had more to say about the price of the products. “Researchers have estimated that a vial of insulin costs less than $7 to manufacture and could be sold profitably at less than $9. In 2019, in response to a Senate inquiry into high insulin prices, Sanofi acknowledged that, by one measure, it cost the company less than $2 to make one of its insulin pens, which at the time carried a list price of $75.

So, we can give Eli Lilly a small clap, but no standing “O”.

Lower prices only solve part of the problem

There are several social determinants of diabetes. People living in poverty suffer from the disease in higher percentages than those that live above the poverty level. Why?

Food is one reason. Those who live in neighborhoods where there are large supermarkets with affordable prices, fresh food, and many options make eating well much easier. In a neighborhood with only fast food restaurants and convenience stores, residents have few options to eat healthy or provide healthy options for their children.

Income determines the ability to purchase fresh food, fruits, vegetables, meat and fish, while limiting processed and fast foods that can lead to weight gain and diabetes. Those who have low-paying jobs often have to work at more than one job, limiting time for shopping and making healthy food preparation difficult.

Education can affect employability and income and may positively influence health literacy.

A perhaps surprising finding from the National Institute of Health (NIH) shows that employees who work shifts rather than normal daytime hours, and those who work particularly long hours are more likely to develop diabetes. Another study found that transportation workers had the highest incidence of diabetes, whereas physicians had the lowest.

Toxic environmental exposures have also been linked to the development of diabetes. As we know, systemic racism has made such exposure more likely to confront those living in marginalized communities. Pollution, ambient noise, synthetic pesticides, unregulated arsenic and other metals/metalloids, and hazardous chemicals in wells in Native American communities, are just some of the problems. The NIH reports more: “Both food packaging and fast-food consumption, which can be high in low-income neighborhoods, can expose people to chemicals known to be endocrine disrupters. Examples include chemicals released from plastic packaging during microwave heating, higher urinary phthalate levels associated with fast food, and higher urinary bisphenol A levels from canned foods. Certain personal care and cosmetic products, which are a source of phthalates and metals (e.g., skin-lightening products, which are high in mercury), are disproportionately marketed to marginalized population subgroups.”

So, yes, we’re glad they lowered the prices on insulin products. But we need to keep our eye on the bigger picture: the need for access to healthy food, jobs with salaries that can support families, and education that offers hope and opportunities.

Maybe Eli Lilly could put some of their millions towards those needs! What if we all messaged Lilly CEO David Ricks on LinkedIn and suggested just that?

Therese (she/her/hers)
Judy (she/her/hers)
Didi (she/her/hers)
Mackenzie (she/her/hers)
Leading Ladies Executive Team
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Ladies@leadingladiesvote.org