The business model of the modern pharmaceutical industry has been based on drugs that alleviate but do not cure the chronic diseases of rich people – depression, hypertension, stomach acidity.  By selling huge volumes of pills at moderate prices, companies could recover the massive expenditures involved in drug development and clinical trials and still make eye watering profits.

But only a few drugs fit that model.  Many recent pharmacological discoveries are relevant to the acute illnesses of a few rather than the continuing ailments of the many.  Drugs such as Halavan, mainly used in patients with advanced metastatic breast cancer, and Sovaldi, a treatment for Hepatitis C.   The US base price of Halavan is $500 per vial and of Sovaldi $1000 per pill.   Since the manufacturing costs are small,  both drugs are extremely profitable – Gilead, which markets Sovaldi, may recoup annually the $11 billion it paid for Pharmasset,  the company which developed the drug.  The main source of revenues for Gilead and other drug companies is the US health care system, funded  through private insurers and Medicare,  The manufacturers of both these drugs have patient access schemes for sufferers without adequate insurance coverage.

Britain’s has the most hard-nosed approach to these issues. New treatments  are assessed by NICE, the National Institute for Health and Care Excellence,  which determines whether they should be made available within  the National Health Service. The key test is quality adjusted life years (QALYS). On that basis Sovaldi, which cures a chronic condition which frequently leads to debilitating and sometimes fatal liver diseases. makes the cut;  Halavan, which  increases the life expectancy of the women prescribed it by  an average of between two and three uncomfortable months, does not.

       But it is not so easy to be hard-nosed.  Hepatitis C is transmitted through poor hygiene and hence associated with deprivation.  Gilead is making Sovaldi available in less developed countries where the disease is widespread at little more than 1% of the US price, though $900 for a course of treatment is still a lot for poor people and creaking healthcare systems. The priced discrimination involved in  Sovaldi’s programme is effectively a mechanism of US foreign aid, never voted on by Congress, and funded by employers and taxpayers,. Yet it may be more effective than most of the programmes which have won legislative approval.

In developed countries Hepatitis C is common among intravenous drug users.  These victims do not tug the heartstrings of the public in the same way as do the potential beneficiaries of Halavan, many of whom believe (almost certainly wrongly) that the drug may save their life.  Vocal public pressures have led the UK government to establish a Cancer Drugs Fund, outside the normal framework of the NHS, and  explicitly devoted to the funding of treatments such as Halavan.

But this is  no more than an expedient political fix.  A mechanism of funding pharmaceutical research which leads to drug prices  far in excess of marginal cost is bound to lead to anguish and injustice. But is there a better funding mechanism? Perhaps governments should finance payment of a national licence fee, with supplies then available at a price close to production cost.

        And why should late stage cancer treatments be prioritised over other costly life extending therapies?   A large and rising  proportion of overall medical expenditure is now devoted to prolonging the lives of the terminally ill. The costs of this activity are potentially unlimited. But  we also need to ask ourselves the questions raised by Atul Gawande in his recent book Being Mortal.  Perhaps the greatest challenges in modern health care are not those of meeting the spiralling cost of advanced medical technologies. They lie in accepting that we are all going to die, and learning to do so with dignity.