Covid-19 has quietly become the gift that keeps on giving for big pharma. The past two years has seen it reap huge profits from Covid vaccines, while simultaneously opposing wider sharing of the technology required to make them. And now there’s a new money-spinner on the rise: Covid antiviral treatment pills. Once again, we’re poised to fall into the same inequality traps we’re caught in with the global vaccine rollout. Both Pfizer and Merck have new antiviral pills rapidly arriving on the market – Paxlovid and molnupiravir respectively. As with the vaccines that came before them, both corporations have made it their business to ultimately decide who gets to make generic versions through the medical patent system – a crucial, life-saving question for millions around the world. And business certainly looks promising. Pfizer alone, freshly cemented as the global Covid-19 vaccine kingpin, expects to make as much as $22bn from its new pill this year, on top of $37bn it made in 2021 from the vaccine. The new medication isn’t coming cheap. Pfizer’s Paxlovid currently costs about $530 for a five-day course of the treatment. Merck’s molnupiravir, now approved for use in the UK, costs about $700. Reportedly, the cost of production for molnupiravir stands at about $17.74. Familiar alarm bells should be ringing. Experts across the board are predicting demand for antiviral drugs will rapidly outpace supply. A World Health Organization report produced in January warned of a “high risk of shortages” of Paxlovid for low- and lower-middle-income countries until generic versions became more widely available, which isn’t likely to be until the second half of 2022 at the earliest. Separate analysis from the data and analytics firm Airfinity suggests that could be as late as early 2023. After an uneven global vaccine rollout, lower-income nations are faced with the prospect of a “wild west” scenario for life-saving pills, too. Pfizer and Merck have chosen to designate a select few generic manufacturers able to produce cheaper versions of their drugs, through the Medicines Patent Pool (MPP). But even with these deals in place, they remain firmly in control, and access to generic versions are within reach of only half the world’s population. A number of countries including Argentina, Brazil, Thailand, Russia, Colombia, Peru, Turkey and Mexico have again been excluded from such licences and are left to try to cut deals for the most expensive products. With so many priced out of the market, global supply will again be prioritised to rich countries, while the companies refuse to make affordable generic antivirals available to everyone wherever they are needed. This is a grim mirror of the dramatically uneven vaccine supply earlier in the pandemic, when rich nations bought up many more doses than they could use. The US, where almost two-thirds (65%) of the population is already fully vaccinated, has reportedly put up more than $10bn for Pfizer’s Paxlovid – more than twice the entire GDP of Sierra Leone, where just 9% of people have the same protections. For less wealthy nations, competition isn’t even a possibility. Meanwhile, Merck continues its “evergreening” patent strategy to extend its monopoly on molnupiravir beyond the standard 20-year protection. Since developing the pill, it has sought at least 53 patent applications to tie it up in legal red tape and stay firmly in control of who gets to make it and where. It has already received emergency approval in the US and Japan, and has been given the green light in the UK. Even in nations within the MPP, where the pills are allowed to be made by select manufacturers, a low cost is not guaranteed. Dr Reddy’s Laboratories in India has made a generic version of Merck’s pill that costs $18 for a course of treatment. However, these costs won’t necessarily be reflected everywhere. Across the border in Bangladesh, the generic version of Pfizer’s pill will cost more than $170 for a course of treatment – prohibitively expensive for a huge number of the population. By restricting which manufacturers may produce a generic version, firms maintain considerable control over the final price. In the past, Gilead’s treatment for hepatitis C, sofosbuvir, only dropped in price consistently when the number of manufacturers was increased without these limits. There is an uncomfortable assumption those in the global north have tacitly begun to accept. When the demand is higher than supply, there is a pecking order: rich nations first, buying up more than they realistically need, while the poorest are forced to scramble to outbid each other over what is left, dramatically overpay, or just wait until they’re affordable and watch death tolls rise. But this supply crisis is entirely artificial. We could produce more – Pfizer and Merck’s drugs are not complex, and could be easily manufactured in a wide range of developing countries if they had access to the knowhow and could avoid the threat of legal action. We need patents and other intellectual property barriers on life-saving medicines to be waived – either voluntarily by companies, or by government decree – so we can quickly supply all countries of the world. We’re doubling down on a two-tier world when it comes to Covid-19 – rich, highly vaccinated nations with easy access to both preventive measures and treatments, and poorer nations trying to get by without either. It’s vital that we don’t sleepwalk into giving corporations so much control over who gets to live and who gets to die, all balanced on what they deem an acceptable bottom line. Othoman Mellouk is a medicine access advocate with the International Treatment Preparedness Coalition