Season 2, Episode 2: Victor Roy Explains How Finance Controls the Price and Value of Medicine

In this episode, Joseph Harris sits down with University of Pennsylvania physician and sociologist Victor Roy. They discuss the issues that are at the core of Dr. Roy's new book, Capitalizing a Cure: How Finance Controls the Price and Value of Medicines, which is available for free online through open access. The discussion covers the financialization of healthcare and medicine and the impact that finance has had on drug pricing and access, including for Hepatitis C treatment, which has a $90,000 price tag but costs just $100 to manufacture. An important thread explores the need to follow the money in global health research and the Health and Political Economy Project, which Dr. Roy directs.

Transcript

Global Health Politics Podcast
Season 2, Episode 2: Victor Roy Explains How Finance Controls the Price and Value of Medicines

SPEAKERS

Joseph Harris, Victor Roy

 Joseph Harris  00:00

Welcome to the Global Health Politics Podcast, where we go beyond the articles and books and have real intimate conversations with people working in the field of global health today.

Joseph Harris  00:18

I'm your host, Joseph Harris. Today, I'm really pleased to be here with Dr Victor Roy. Dr Roy is a family physician and sociologist who serves as Assistant Professor in the Department of Family Medicine and Community Health at the University of Pennsylvania's Perelman School of Medicine. Dr Roy is one of the few MD PhDs in the discipline of sociology today, along with Nicholas Christakis at Yale and Jonathan Metzl at Vanderbilt, He is the Senior Director of the new Health and Political Economy Project, which is a multi-institutional partnership between the New School, Penn, and CUNY. He is also author of the new book "Capitalizing a Cure: How Finance Controls the Price and Value of Medicine" published by University of California Press. The book is about finance capitalism's role in drug pricing and access to curative hepatitis C medication. Dr Roy, Welcome to the Global Health politics podcast. It's a pleasure to have you. 

Victor Roy  01:19

Thank you so much for having me. 

Joseph Harris  01:21

So what experiences led you to want to become both a physician and a sociologist?

Victor Roy  01:28

So, you know, I could go all the way back to the beginning, which is that my parents are from rural villages about four hours west of Kolkata in India. And the story is that my maternal grandfather. My maternal grandfather was trained in British air medical school in Kolkata, and went back to his kind of villages that he grew up in, and ended up there for 60 years as a family doctor and, and then my paternal grandfather was a village health worker, and so when he didn't know what to do with a patient, he would refer to my maternal grandfather. So I'm the product of a community health referral pathway. That's how the families knew each other. And I spent a lot of time, I grew up in New Jersey, but I spent a lot of my summers in India, in the rural villages, watching my grandfathers, and in particular, my maternal grandfather be a doctor to many people who had very different life circumstances than the ones that my family did in suburban New Jersey, and so I think from a very early point, I saw a role model of a doctor who took care of his community but also had an understanding or a sense that there was inequality, that life circumstances could be really different, not by choice, but by a set of, you know, structures that those things, I think, are dynamics like I became more keenly, you know, actually familiar with by studying them when I went to college at Northwestern in kind of the mid 2000s and global health had just kind of become a thing on campuses and and a lot of something that students were interested in thinking about. And a lot of the conversations were about, kind of the social and structural forces that were driving epidemics like HIV/AIDS. And that's how kind of got interested in, in in, in the sociology piece, that there was a different set of tools. Maybe I could be a doctor, but maybe I could also think about the social sciences in terms of how disease is patterned, and kind of the social and structural forces that drive them.

Joseph Harris  03:37

Did you have an idea at that time of what you wanted to do with his degree?

Victor Roy  03:42

No, I did not. The joke is, so I actually went to Northwestern because they had a seven year medical program, much like BU actually does too. I interviewed here. I got into the program at Northwestern. But the joke is, I turned the seven year program into a 13 year program, mostly because at the time, I figured I'd just go be a doctor, but then going to college opened my mind up to all these other fields and disciplines, including the, you know, sociology. And it wasn't really, it was actually a professor and a set of classes that kind of turned me on to questions of political economy that I started thinking, Well, you know, I could pursue maybe a dual degree. And at the time, Northwestern didn't really allow that in the social sciences, if you wanted to do dual training, you had to be like an epidemiologist or a lab or a bench scientist. And so I kind of stumbled my way into basically putting together my own kind of dual degree program in which the PhD in Sociology was something I like came about later as a way of being able to do the clinical training but also train in sociology. 

Joseph Harris  04:57

And what's the journey been like so far? Would you say? 

Victor Roy  05:00

And I'd say it's been a constant kind of iterative process where, you know, I think in I think there's a recognition by both fields that it's valuable, that I did the other thing, but not quite always an easy translation. And so when it's in the medical community, you know, the way that people think about research is like quite different. And, you know, the conversation is like, you know, what's the primary outcome you're looking at and trying to structure some, you know, a data set that will help us evaluate an exposure and an outcome. And sociologists also do that, of course, but might think about the whole framing of a question differently. And then in sociology, you know, I think my experience as a clinician, as a practitioner, has always made me want to, like, really connect theory to practice, because ultimately, you know, I think ultimately I feel accountable to my patients and public health more broadly. And so I think sometimes figuring out how I can do that in the most constructive way is is a process. But I have a lot of fun with being able to do that back and forth. I think it's the the ideas and the questions I get to think about are more fruitful because of that exchange. But it's definitely every step I had to figure out, okay, how do I bring these together? And the path isn't, you know, straightforward.

Joseph Harris  06:37

I love that. When you were a university, you served as national director of a student organization called GlobeMed. How did you become involved in that? And what were you doing there?

Victor Roy  06:48

Yeah, so, you know, I shared a little bit about the fact that I think a lot of young people at the time were getting more interested in thinking about health around the world, and I think the HIV/AIDS movement had really sparked that interest. There was also conversations around global poverty, the millennium development goals, goals, and so I think I knew in college I wanted to be able to spend some time abroad. And for me, it wasn't like it was a little bit different, perhaps than some others, in that I'd already been doing that since I was, like, literally 10 months old, but I wanted to continue that, maybe in different settings. And so I had the opportunity to go on some trips that really like kind of short term voluntourism. And I think that really for me, was kind of really challenging, because I had, I had done the kinds of experiences as a family member, where I was rooted in a community. I was with people thinking about, you know, or talking about patients with my grandfather, and here I was kind of as an outsider on these, like, 10-day trips trying to distribute medications or vitamins and doing really kind of not community engaged work at all, and not partnership. And I realized that that was all that had a lot, there's a lot of harm potentially, in that kind of a model of engagement. 

And there were a lot of my peers were having the same experience where, yes, everyone wanted to kind of learn about the rest of the world, but how are we doing that? And, yeah, and, and also, you know, people wanted to make a positive difference, but were we actually doing harm? And so that's where the idea of glove med came out was, was the concept of like, how do we as young people partner with community organizations and in longitudinal relationships and actually hopefully learn something in the process and hopefully be able to make a difference over the course of a longer period of Time? So university campuses would partner with community organization, you know, over many, many years. So one of our chapters partnered with a group in Rwanda, for over a decade, and students had the chance to go there and experience the work that was happening there over the course of a longer period. In terms of the summer was still short, but still as part of the longitudinal relationship. And then students would like fundraise for projects during the course of the academic year. And this was all kind of, there's like health equity curriculum that students would engage in throughout the year. So the idea was really to get young people involved in a more kind of immersive and long term, kind of partnership oriented way, that that would hopefully inspire people to do this kind of work and take those values with them in whatever field they do go into in the future. That was the work at the time, is to kind of build that out and build up the training and the partnership model.

Joseph Harris  08:03

Yeah, one of the books that I have my students read in my global health politics workshop or global health politics classes. Judy Lasker’s "Hoping to Help" that gets it so those ethical challenges, of the promise and the pitfalls I think of those short term volunteers experiences, can I ask how? How, if at all, did the experiences with GlobeMed affect or inform your clinical practice and your experiences as a scholar and interests? 

Victor Roy  09:44

I think two different ways. I mean, I think as a clinician, it ultimately reinforced my direction of wanting to be a family doctor, because I think working more engaged with a place or community was something that I saw a deep value in through GlobeMed, but also in medicine, I saw family doctors as the ones kind of doing that as clinicians. And so I'm excited that I'm going to be joining next fall. You know, as an assistant professor in a family medicine Community Health Department at Penn, with the chance to hopefully, kind of continue that approach and orientation of clinical practice, I think, as a researcher, you know, lot of my work is ultimately focused on larger questions of kind of economic policy and structural drivers and health, and we're going to get into some of that. And I think oftentimes I saw a lot of the organizations that I was working with really on the front lines, doing really important work, but constrained by other dynamics that were having to do with how government and business. And, you know, even academia were kind of playing a role in shaping the trajectory of resources or ideas, and I wanted to study some of that. And so that's how kind of I came into what I ultimately ended up doing with my sociology degree.

Joseph Harris  11:38

Well, in your scholarly work, you've demonstrated a particular interest in drug pricing and access to medicine. What drew you to those issues?

Victor Roy  11:48

So I think with the question of access to medicines, ultimately, I think there are, there are these really stark cases where we have biomedical breakthroughs and HIV AIDS was one of them, and I had a chance to study that as a student. And then, as I was starting my doctorate, these new treatments for hep C were approved. And I think as, at that time as a medical student, slash, you know, sociology trainee, saw a future in which I thought that we had maybe tackled some of these issues in the previous set of movements, but realized that there was a whole new set of issues that were, they'll stay with us, and that they were these really clear kind of areas of moral clarity where you've got a treatment for a disease that can be cured, and the price is something that is a huge obstacle and leads to a whole set of knock on ripple effects that made it really impossible for people to benefit from the fruits of contemporary biomedical innovation, and so it seemed like a really important area to focus my efforts on, through through my research, and I started realizing that there were an important set of questions that hadn't actually been asked and that I could make contribution with through the social sciences. I didn't know that at the beginning, I had to come to that. And there were definitely times where I thought, maybe everybody else is kind of knows what the answer is here, and I'm not sure what there is to really discover from a sociological or kind of policy standpoint, but I'm glad I stuck with it.

Joseph Harris  13:37

Yeah. Well, I think all of us who do a PhD have that, you know, feeling insecurity, not sure either where this is going or if it will matter, but ultimately we wind up somewhere and usually discover something interesting. I think in the process, in your book, Capitalizing a Cure, you make this distinction between price and value. Can you talk a little bit more about that? What's the difference between price and value. Why is it important?

Victor Roy  14:02

Yeah, so this is a really complex but important question that, of course, affects the drug pricing, and we can talk more about the rest of the book in a bit, but just to kind of back up a little in terms of providing context around the price and value questions through the case study of drugs. Typically, we have had a debate about why drugs are priced, what they are based on this whole conversation around what it costs to make them,research and development costs, and implicit in that conversation is that we as society grant patents to companies so that they are able to recoup the costs, ultimately, because they're gonna be able to price as a monopolist on that particular treatment, potentially, or maybe have very limited competition, so that they can recoup the costs of developing them. And there's been a whole decade long debate about that and trying to prove what it costs to develop a new treatment. And what was really fascinating about the Hep C case and the kind of debates that we're having now around breakthrough treatments in particular, is the prices actually reflect the value that these treatments have to society, which is very different way of thinking about price in value. And so, in the Hep C case, the argument was made, well, because these are curative treatments, we shouldn't be debating the price as something bad. It's actually reflecting the fact that, because they're cured of treatments, you know, I'll just say Hepatitis C is a condition that leads to liver end stage organ failure and can be a terrible death and lots of hospitalization is a huge expense to society. Well, if they're going to save it's going to save society money curing them. Well, then that's what the price is. It represents this like kind of value to society in the future. That's very different than thinking about prices connected to some kind of material labor, right? So it's a different theory around value that underlies that other version of pricing, where you can say, well, if these are the inputs, then we can price based on, you know, making sure that you earn some profit based on the input that you had into the process. And that kind of is a little bit more akin to, if we want to get into the kind of social theory, is like a labor theory of value, whereas this other version of value is kind of constructed as more kind of a neoclassical version of kind of economic value as what is the consumer preference here, in terms of what they're willing to pay and irrespective of who developed it, what the inputs were into making it and of course, there's all these problems that we run into when that is brought into the arena of health, right? Because, of course, what is a government willing to pay on behalf of its citizens? What is an individual willing to pay for their own health? Are questions that you know aren't just simple economic questions, right? They bring in other kind of values that are the source of so much controversy around these issues.

Joseph Harris  17:08

They have concrete meaning in people's lives, right? People can afford it or not. Well, tell us a little bit more about capitalizing a cure which focuses specifically on the price and value of hepatitis C drugs.

Victor Roy  17:21

So, like I was saying, these treatments were launched in late 2013 in the US. They were approved, and it's a treatment for a disease that affects in the US, perhaps like 4 million people around the world, something like 70 million people, and it's a virus that you can get through in an older time, blood transfusions, when they weren't screened for hep C, but then more recently, it's a lot of it has been transmitted through injecting drug use, through addiction, and obviously in the opioid epidemic in the US, but as well in many other countries. And so these treatments were long awaited, and they are amazing in that. And the treatments I particularly focused on were produced by Gilead. They cured the treatment within three months of taking them a daily pill. And they became dubbed $1,000 a day pill because they were priced about at $90,000 for the three month regimen. And what was really interesting is, of course, if you do the math, it probably costs less than $100 to manufacture them, but the price of $90,000 in part because the price of the existing treatments were already 60, $70,000 and the existing treatments were not so great and didn't lead to higher cure rates, or not as high as what Gilead treatments were offering. So that just triggered a whole controversy in which the governments around the world and in the US, rationed the treatment, and in many cases, actually made it only possible for people to get access to it once the disease has progressed to a certain level of damage, of what we call cirrhosis. 

Victor Roy  19:14

And so this debate that we just spoke about price and value is kind of where the whole debate center around where a lot of folks are saying, well, these treatments are really valuable. They have high value, and so we should, we should pay for it. And of course, governments were saying, Well, this will, if you multiply that price by the number of patients that could benefit, it would really affect our, literally, our ability to pay for like education or other, there'd be huge opportunity costs. And so I dug into essentially the question of where do these ideas around price and values and value come from? And realized through my research that actually they were located in a place that hadn't gotten as much attention, much of the attention before. Focused primarily on just the firm, like Gilead or other pharmaceutical companies, and that is actually the financial incentives, but also financial markets and Gilead relationship with them, and kind of the financialization of corporations over the last 20 or 30 years. Some of the ideas that have come along with that we're actually kind of colonizing public health. And so the book is really a work of trying to trace some of that, and I can kind of describe that a little bit more, but really is looking at the influence of the financial sector in shaping how we make price and value treatments.

Joseph Harris  20:43

And it seems like this issue of high cost medication, it's not going away. You talked early on about AIDS drugs, and at the time, I remember they were going for $10,000 a year, and before they were driven down to $300 a year. So now we're talking about these drugs $80,000 or $90,000 a year or for a course of treatment. And now I'm aware that there's one or $2 million drugs. Is that right? What kind of lessons does your book offer for these other cases, like the million dollar case of spinal muscular atrophy, or sickle cell anemia, or even diabetes and insulin.

Victor Roy  21:24

So, you know, I think that it offers one is a diagnosis, and the diagnosis here is that what was happening with medications and biomedical research and development is really a turn to to treating them as financial assets, right? And so how companies often view, you know, how we've thought about companies for a long time, I think, is, these are companies that are integrated, you know, research and development firms. You know, they're bringing, they're translating science into products. And through my research, I show in Gilead case, for example, how much of their strategy is organized around acquiring assets that they think will be valuable in the future, and pricing them in a way that then allows them to accumulate the kind of capital that will allow them to acquire more assets. And so, you know, which is part of the dynamic around how they're trying to then drive a big chunk of the profits that they earn to shareholders, right? And so a lot of what happens in the case of Gilead is, you know, how do we acquire drugs and then do payouts to shareholders like that's kind of the two main strategies. At one point, the CEO, even on an earnings call, says like those are, that's their bread and butter is acquisitions and buybacks, which is the form of driving payouts to shareholders. And so locates the dynamics around this as something that you know, trying to name and shame, individual firms alone, while it might be politically helpful, they're responding to a whole set of financial incentives that, if we don't actually untangle and unpack, you know, we will just be like playing a whack a mole strategy. So I think this is where the treatment, then is actually is a menu of options. I think it depends on the treatment. So if you're talking if you're talking about really high price breakthroughs for something like sickle cell, you know, I think over time, governments have to assert creative options, or develop creative options to actually either negotiate with these companies or deal with the underlying intellectual property, particularly in cases where public investment was a big part of the process. 

Victor Roy  23:46

And so we saw some of those examples in with hep C, where the state of Louisiana decided, given the large number of patients with hep C in that state, and the fact that they couldn't afford it, the price points being offered to them that they would really. They played some hardball with the companies, and they said, Well, we're gonna, we're gonna pursue more radical measures to ultimately, you know, reimburse you for intellectual, basically pay, use a rule called 1498 that would actually address the underlying intellectual property ownership claims that Gilead has, and say, Well, if the government has a public interest here, we can actually, you know, offer royalties and but we're going to have, you know, we're going to be able to license this to a generic company, right? And that actually got Louisiana to the table this, I mean, Gilead to the table to say, well, we don't necessarily want to do that, but we'll, maybe we'll be part of a different deal. And so Louisiana offers, you know, what's being called, a Netflix model, which is, we will, as a state, offer you some lump sum payment in return for an unlimited access to these treatments over a period of time. And so that was a creative way of actually incentivizing Gilead to, you know, be able to essentially get access to patients that were going to get their treatment now that was weren't getting it before, but incentivizes the health system to actually go out and find those patients, and so that's been a model that actually comes from Australia, but I think could be useful in other cases of really high price treatments, where the government says, you know, we can give you a lump sum payment. It's not going to be anywhere near what you're getting from other payers, but it's still going to be some reimbursement. And at the same time, it incentivizes the health system to really, actually go and treat these patients to, you know. 

Victor Roy  25:38

So that's just one of the, one of the kind of options and for cases like insulin, right? So this is a very different kind of case where the existing pharmaceutical companies, you know, insulin has been around for a long time, they have figured out ways to basically own intellectual property around these treatments for much longer than they've actually really made true innovations around these treatments. But so how, you know, they've created lots of strategies that have allowed them to kind of manage these as financial assets, right? And what California is doing is really interesting, where they're saying, Well, you know, we're going to try and actually create public manufacturing capacity, and we're going to try and actually produce insulin, and they're partnering with a nonprofit manufacturer to try and do that. And so there are probably some challenges there in terms of how the arrangement is going to come together, but at least it's an idea of "okay, government can take an active role in actually providing a public option," and just even the presence of the public option will discipline the private actors, while also creating state capacity. And so multiple states now in the US are actually considering bills to actually launch public manufacturing capacity. And so you could imagine a world in which Michigan makes inhalers, California makes insulin, and then they start buying from each other and just creating a whole different market that exists outside of the market that's driven by corporate shareholder and maximizing value for them.

Joseph Harris  26:26

So, I mean, this sounds like, in a way, that it's, you know, through government, using leverage that is at its disposal, breaking apart this illusion of value and perhaps moving back towards price or labor values you talked about. Is that fair?

Victor Roy  27:27

It is because in these cases, you know, government can then ultimately price closer to what it costs to produce the product with a margin for profit depending on who the actor is that they're working with, right? But it's driven by a different set of economic logics, and that's the that is, that is the approach here that isn't really possible under the existing circumstances where, yeah, we're having to have a debate about, "well, as the price, should it be 2.2 million treatment for sickle cell, or should it be 2.6?" And you know that there's a lot of math going into trying to figure out how to objectively, you know, point to this is the underlying rationale, and that's why these debates are so contentious, because you actually can't really, really point. You're making a narrative case with numbers, right? But it's still, you know, ultimately, a lot about narrative and, and that's actually partly why this is really interesting, right? Because you realize, then it's, this is not that didn't come from some, you know, there's no law. There's no sort of text. You know, like some econ textbook that says: We're ultimately going to get to a future in which prices will just be this, because that is what innovation costs. This is the law of innovation and pricing. There is no such thing, right? It requires a lot of market actors to do a lot of storytelling using different tools. 

Joseph Harris  28:55

Yeah well, how has capitalizing a cure been received in the business and in the policy worlds? 

Victor Roy  29:02

So, you know, it's interesting, I think in the business worlds, I've had a chance to engage with a few folks. But, you know, this is not obviously an argument that many in the business world will, as currently constructed, or at least publicly, be excited by. And so I was sharing before that, I published this article that relates to my book in 2016 around kind of this business model of acquisitions and then share buybacks and kind of what that entails, and the implications it's had for access to medicines and Gilead responded to the article in the BMJ within about 48 hours, with about, you know, a pretty lengthy response and and so I think it struck a chord, because it I think the underlying analysis around the business model is one that ultimately they couldn't really refute in their response. Um, and so it becomes more about, then coming up with a set of stories to kind of justify this, this kind of business model around doing, you know, acquisitions and buybacks. Because the story of, kind of developing the research and taking it all the way to products was one that I kind of, you know, challenge directly in the book. 

Victor Roy  30:22

But I think, you know, there are a lot of people in the business community that didn't get into this work to just, you know, charge really, really high prices. I think that they feel like there are problems with the existing setup as it is. They know they benefit from it, so change probably won't come from them. But I've had instances in which I've been to seminars where a venture capital. There was a seminar, actually, a few months ago at Yale, where we were listening to a venture capitalist, and he had introductions, and say, I bought your book and I sent it to a bunch of my friends at Gilead too. So it's interesting to see, like some of that reception, that people want to engage with it. I think from the policy angle, there's, there's two different directions. One is actually on the Hep C case itself, the US is considering a much bigger federal program to try and tackle Hep C in a way that we haven't been able to for a decade, in part because, not only because, but in part because of the prices, and so it's been exciting to know that, you know, I've had a chance to share this book with that team, and at least one member of the kind of team has read it. So that's that's exciting. I don't know exactly how it's shaping their thinking yet, but, you know, I think that it's helpful to have this evidence and this kind of framing and understanding of the problem at that level. And then the other piece, I think, is just connecting this case study to much broader conversation that's emerging around kind of the role of financial logics the financial sector in in health, and some of the real dangers that I think it can pose. And so I had an article published in January titled "the financialization of health in the US" that I co-authored with colleagues at UChicago in the New England Journal of Medicine. And so I think that wouldn't have happened if I hadn't been able to put these ideas together in the book. And the fact that the New England Journal of Medicine is paying attention and publishing on "the financialization of health" was kind of a breakthrough, and I feel like means that more people will pay attention when that article came out, we had multiple requests and engagements from Senate offices. I had chance to talk with a few, so there's definitely at least interest. 

Joseph Harris  32:42

Yeah, well, that's exciting. I'm glad to hear that the conversation has already been so impactful and wide ranging. Are there activist movements and other organizations that are working on these issues? Whose work inspires you or who you're following?

Victor Roy  32:59

So on the US side, I would say, and actually, they do a lot of work internationally too, is T1 so this is a group that has been organized around insulin, because T1 stands for basically type one diabetes. And so they've really organized. It's a patient kind of driven movement, but they've been the ones who have really helped, I think, get public production of insulin on the agenda. So they've been very engaged in the California process and in state houses across the country trying to really help develop kind of this idea of there should be a public option for manufacturing of essential medications. And to see them have headway, I think just shows the power of kind of bottom up organizing and to create change. I think other groups that have made a big impact, IMac, is another group. They're based out of New York. They've done a lot of work in the US, but also internationally, but they've been a lot of work just focusing on the problem of intellectual property. That intellectual property wasn't designed to be so broad and wide. It was actually supposed to reward innovation, and now it's rewarding something else, and that actually has a big impact on if innovation is what we want, then we actually have to have a different view of intellectual property that is more narrow actually, and more rewarding of actual innovation, because otherwise it rewards a lot of other kinds of behavior. That actually incentivizes actors to, you know, make incremental changes, to get new patents, to own property for as long as they can, to reap the financial awards, rather than actually the breakthroughs that people, at least in the industry, ostensibly talk about wanting to create. 

Joseph Harris  32:59

Tell us about this really interesting multi institutional partnership on political economy and health that you're directing.

Victor Roy  34:45

Yeah, so this is an initiative. That's very much in the incubation phase called the Health and Political Economy Project. And I'll say the premise really is that we see an opportunity to learn from other sectors and fields where there's really active momentum to kind of build beyond kind of the 40 to 50 Year neoliberal project that we've all experienced and are engaged in and to really bring some of those ideas into health, but also connect actors that are already doing this within health to kind of bring in new economic thinking. And what does that mean? Right? That's a very broad kind of agenda, so part of what we've defined, and when I say "we", it's Dave Chokshi, who is the former health commissioner for the New York City Health Department, and Darrick Hamilton, who's an economist at the New School, who's done a lot of work around one well, he's done a lot of work on different topics, but he's also well known for his work on baby bonds, which is kind of the idea of creating a birth rate to to wealth, not just an income floor, but the idea that young people, at the age of 18 would actually get an endowment from government, just like many of us from well to do families actually get from our own families? So, and it's an effort to actually close the racial wealth gap in the US, and it's an experiment that's already live in Connecticut. So I'll just elaborate on this, because it's an example of a kind of policy idea that creates a new, I think, political economy that also is rooted more in health, but in Connecticut, every baby born on Medicaid will now, at the age of 18, be eligible for a state bond, basically that has been invested on their behalf over the course of 18 years. And between the age of 18 and 30, that child can then use that money to get an education, buy a home or start a business. And so sorry, that was a tangent, but that's what Darrick Hamilton is one of the policies that he's engaged in, and we've kind of thought about this as a field catalyst initiative that would really drive scholars, practitioners and organizers, as well as part of this to think about how we can connect the dots around ideas like public manufacturing of insulin, around community health workers that actually have, you know, really good labor protections, right, that are good, good potential union jobs. Or, you know, and kind of connecting up with some of the Union movements that are that we're starting to see around health workers in the US and even around the world, to kind of build an agenda that is not only critical, critical of kind of the ways in which neoliberalism has shaped health and health policy, but also hopefully shapes a whole set of constructive agendas that that actually carries them into boardrooms and policy conversations in ways that I think we haven't yet. So stay tuned. We're still working this out in terms of what the specific issues will be, and kind of the combination that we see of research, policy development and public engagement, and kind of how that will come together around this. But I think we're excited that people are eager for this kind of a space to develop and for them to engage in that.

Joseph Harris  38:36

That's wonderful. I want to take a minute to ask you a few questions about how you think about the research process. What would you say are the most meaningful parts of the research process?

Victor Roy  38:50

I think probably one of the most meaningful parts is just, how do you develop, you know, a question. And for me, that's oftentimes the most exciting but the most harrowing part, because it's the translation of an inkling of an of an idea, or maybe even something that's like, you know, an issue that's like, burning inside of you that you want to really tackle or take on, but then actually turning it into a really tractable question that will actually produce something that will be impactful. Like, that's that initial part, I think is, is a really meaningful part. Think it requires, in some ways, you know, I think there are later parts that require a lot of courage to but, like, it requires a lot of courage to kind of take on something that maybe you don't know a ton about, and then figure out, okay, there is a contribution to make. What's the gap here? And to be able to shape a question. So just with the example of the Hep C case right, like the initial bits that I got from all my mentors and then people from the policy world was all Victor, like, maybe you should just do what's been done in the past for hep C, but do it for hep C, which is try and find a way to estimate the R&D costs. Yes, that went into making these treatments. And I quickly realized, well, not quickly, but over time, realized that that actually wasn't gonna be the right question, because Gilead had bought these treatments, bought pharmaceutical company that they ultimately got the compound, the fossil fuel based compound that was critical to the Hep C cures, they bought it for $11 billion and so that $11 billion figure was actually kind of like a sociological phenomenon that couldn't just be understood by quantitating some kind of underlying, you know, R&D costs, right? That was something I needed to really think hard about, you know, this whole dynamic around the financialization of health. And so then my research question became more about, how does the financialization of Biomedical Research and Development influence the pricing of medicines, which is a very different kind of question than you know, what are the R&D costs behind making this treatment? And one is, you know, one required a whole different analytical framework, and that's, you know, wise to  sociologist, because sociology had a lot to bring to that first question, where the latter question seemed like more of an empirical exercise that was about producing a data point, but it would be abstracted from the actual debate, and also how the treatments were actually developed and priced and valued. So that's  just an example of, like, kind of how I think coming to the question is probably one of the most meaningful parts and one of the hardest.

Joseph Harris  41:36

What would you say have been some of the biggest influences in your work?

Victor Roy  41:42

So, you know, with I think there have been different chapters of influence. So I think, like many, many young people on college campuses in the mid 2000s late 2000s you know, being influenced by people like Paul Farmer and medical and his medical anthropology and that of his colleagues, people like Salman Keshavjee and others, who really connected ideas of structural violence and and wider kind of political economy dynamics to actually what was happening in the clinic or the patients that they were seeing. And that, to me, always seemed like a powerful way of connecting big, what can feel like abstract forces down to a patient experience and or a human experience. And so I think that is something that I've tried to carry forward. I think Hep C ultimately allowed me to take financialization and turn it into, you know, connecting it down to questions of the liver, right. And so I think that's always been, been an influence. I think during my PhD, actually, I came across some economic thinkers like Mariana Mazzukato And who, you know, normally, I wouldn't necessarily, you wouldn't necessarily read in in sociology, but has had a lot in terms of contribution to thinking about the role of government, the role of the state as an entrepreneurial actor behind so many of our innovations, and ultimately helping us think about value in a little bit of a different way, and trying to connect it back to, you know, how do we actually assess who creates value and who extracts it? Right? That these should be questions that should be on the table as part of our policy debates, so that that was really influential during the course of the PhD, and I think throughout the throughout the path, you know, Bourdieu has been somebody that I've read, and particularly, you know, he has this, has this line that, you know, it's not how prices determine everything, but it's everything that determine prices. And I think that that is a very powerful sociological synthesis of, like, what the scholarship has been about. It's everything that determines prices, right? That then, of course, impacts people's health, sure, but of course, you know, he had contributed, gave me a kind of a set of tools around how to think about capital and how they how it operates in these fields, and I don't make explicit in the book, but are definitely behind the way I thought about the research.

Joseph Harris  44:21

Yeah, that's great. Do you feel there are any parts the research process that just don't get enough attention, or that we don't talk about enough? 

Victor Roy  44:30

Well, I guess for me, you know, maybe it does get attention, but I think for me, a part of the project that was, besides the what I already talked about with the actual coming to the question piece. So I think oftentimes research can be described in very linear ways, which is like you come up with a question, you collect your data, you interpret it, and then you write. And I think especially for those of us doing qualitative work, doing potentially work that also involves history. I. You know, I think the interplay between theory and data is one of the most interesting parts, and is very non linear. Ultimately, you know, I don't think I really came across the financialization literature, for example, until, like, I was already kind of into my early data collection process, and I realized, actually I had to kind of back up and maybe ask the question a bit differently. And so, you know, I always think, like research actually is like an iteration between, you know, theory data and a provisional representation of what the hell you think is going on. And then that's actually the, actually, you know, actually quite a rigorous way of doing social analysis is because then you are repeating, you know, as you repeat that you refine and refine and refine, and actually have a much thicker description of actually the social phenomenon you're interested in, versus, kind of, I think too often, especially scientific manuscripts, kind of present research as like this linear process, from, you know, your methods to your results to your discussion in ways that, first of all, oftentimes, doesn't actually play out that way. But I think oftentimes, the most powerful kind of rigorous research comes out of an interplay between the theory via the data that you're collecting and provisional representations that get less and less provisional as you go forward.

Joseph Harris  46:32

No, I love that. It made me think about, you know, the theory that I put in my original dissertation proposal, and how, in some ways it was almost different theory when I was actually writing the dissertation up, right? I came to see the data in totally different ways. And, you know, its relevance to what I had thought was no longer and there were other things out there that spoke to it more. I love that. Let's see, are there any practices or habits you found indispensable in helping you through this long journey of conducting research in writing?

Victor Roy  47:09

I think trying to do my best with trying to write memos during the process is something that I realized after every couple of interviews, I just needed to write something down Like again. It was the provisional representation piece that helped quite a bit, because then finally, when I did start actually writing up, it didn't feel, first of all, totally overwhelming, but also helped me figure out, you know, either directions I needed to go that were a little bit different and with people I was interviewing, or kind of data sources that I was looking at. So just an example is like I in the course of the research, initially, had done a bunch of interviews, but and done a lot of reviewing medical and scientific journals as well as late press descriptions of kind of what was going on. But then I realized that I needed to look at what Gilly was telling Wall Street. So the earnings calls transcripts became really powerful sources and data, because it was showing me directly and showing, I think, ultimately, and I'll share this a little bit in my talk later, but also in my book, the relationship between the financial sector and the company in a very direct way, because what are the questions that they're interested in, and what are their responses? And so memory helped me kind of understand, even, like, the sources of data that might because it made me realize, like, that's a gap, and what data could help address that. So the earnings calls transcript became a really powerful source of data. And then I think in terms of just practice, I'm, I am. I tend to be a morning person, so I actually write best in the morning. So I generally tend to chunk like writing in the morning, and then in the afternoon will be the time where I read what I wrote, or, you know, I might even like outline what I think I want to write about tomorrow. And so I always try and chunk up my day so I don't do any one thing all day, because I find that I have diminishing returns after about four hours of trying to do any one thing. And so I always kind of split up my day. And the parts of the day that I know I won't do my freshest thinking is the day parts of the day where I will do, you know, the pieces that are a little bit less than mentally taxing, which might be like, well, let me just at least put some bullets down on paper, so I have to start with the next day. 

Joseph Harris  49:25

Yeah, that's great. And I love this point about memos, because it does get overwhelming. I'm just starting a new project, and I think you just made me realize I need to start writing memos, because otherwise it's gonna feel overwhelming. What do you do when you get out to 120 interviews? Right? If you could give first year PhD students doing work on global health, one piece of advice, what would you say? 

Victor Roy  49:49

So I'd say, and this might be less relevant to just or not particular to global health, okay, but I think it. Is, you know, you have to give yourself permission to kind of follow a question where it leads you. Yeah, and I think, I think alongside that, alongside that, is a very, maybe it's a second piece of advice. Sorry, not just one, but it's okay. But, you know, I think pursuing questions where you're genuinely also, like interested in whether it's the people that you're researching alongside, or, you know, the place you want to research like the people matter as part of the research process. I think as academics and scholars, we oftentimes think about the question or, what am I interested in? Is, what is going to be my, you know, one liner, right? What am I the expert in? And I would just say, like, try and be an expert in things that also, like, you're excited to be or happy to being around the people that that research is going to make you be in company with in whatever way, whether it's your colleagues or whether it's who you're researching with, or, you know, the subjects you're engaged in, like the people matter as part of the process, in addition to kind of giving yourself permission to follow a question where it leads. Of course, as somebody who likes political economy, I always add the third bit around, just follow the money. Because I think if you want to study global health, you should follow the money, because that has a lot to do with how things are structured, and not only that, but it's important to trace and follow. 

Joseph Harris  51:28

I love that. I love that. Well, we've been talking today here with Dr Victor Roy. He's a family physician and sociologist, currently postdoctoral fellow at Yale University and soon to be Assistant Professor Community Medicine at University of Pennsylvania, and most importantly, the author of the brand new book, Capitalizing a Cure: How Finance Controls the Price and Value of Medicine. Please go out and get it if you don't have it already. Victor, it's been a real pleasure to have you here.

Victor Roy  51:59

Thank you so much for having me, and the book is available open access so you can download it for free.

Joseph Harris  52:03

All right, I love that. All right, you've got no excuse now. All right, thanks again for joining the Global Health politics podcast. This episode of the Global Health Politics Podcast was produced by Noor Darwish. Thanks for listening.

This transcription was produced with the assistance of Cenyao Xiong.