Lars Reiben Sorensen
Talking with the CEO of Novo Nordisk, Lars Reiben Sorensen
Q: For some very poor people in the U.S. and around the world, insulin is too expensive to purchase. Do you believe that an insulin company has a responsibility to provide insulin -- for free -- to any diabetic who cannot afford it?
A: Access to health is something Novo Nordisk has worked actively to address for a number of years.
Among other things, we helped found the independent non-profit organization, the World Diabetes Foundation (WDF), in 2001 with a grant of 500 million Danish crowns (about 67 million euros or 90 million dollars) to be spent over 10 years. The WDF works to build capacity, infrastructures and access to diabetes care in the poorest parts of the world. To date the WDF has started 57 ongoing projects in more than 65 countries with an estimated direct impact on 24 million people in the developing world.
Novo Nordisk also offers human insulin to the public health systems in the 50 least developed countries (LCDs), as defined by the UN, at prices not to exceed 20% of the average price in North America, Europe and Japan. In 2005, Novo Nordisk offered this pricing policy to all 50 countries and sold human insulin in a total of 32 countries at or below this price.
Compared to many other drugs, insulin is already a low cost medication that most healthcare systems can afford. However, lowering costs of medicine or giving away free products are not the sustainable answer to a long-term problem. Indeed, in some countries it is not the cost of the insulin but the distribution systems within the country that prevent access for patients in need of this life-saving treatment. We need initiatives that address the root cause of the problem of limited access to health care providers and medications.
Lars Rebien Sorensen does not have diabetes, but he may be the most important business leader in the field today. As president and chief executive officer of Novo Nordisk, he heads the world’s largest insulin company – its products are used by 15 million people around the globe each day – and Novo has taken the lead on raising awareness of the epidemic. Most recently, it sponsored the Global Changing Diabetes Leadership Forum in New York, which we attended in early March, and former President Bill Clinton was the keynote speaker. He emphasized that three things are needed to slow down the pandemic: vision, leadership, and money. Right now, Mr. Sorensen and his company are providing all three. In a conversation with Kelly Close and Jim Hirsch, Mr. Lars Sorensen, CEO of Novo Nordisk, discussed the need for governments to recognize that health care is not about treating diseases but about investing in the future, Novo’s next generation of insulins, and the need for the pharmaceutical industry to repair its reputation.
Kelly: Thank you so much for taking the time to speak with us. What steps would you like to see industry, government, and health care professionals take to improve diabetes care?
Mr. Sorensen: I think we're basically talking about a problem of chronic disease, which is the biggest public health threat we have in many societies. And we believe diabetes is a model that can be used for how to deal with it, how to monitor it, how to treat it. But no single institution is able to solve this problem on its own, and therefore, we need to come together – patient associations, health professionals, governments, NGOs (non-governmental aid organizations), and industry – because otherwise we can't solve this.
Jim: But once everyone comes together, what should they be doing?
Mr. Sorensen: Well, I think we need to recognize that we each can play a role, and if we work together, I think there's a win/win situation possible. For example, ideally, we should create health care systems that are capable of preventing chronic disease, but if that’s not possible, health care systems should diagnose and treat early rather than treating late. Then it's a win/win situation for everybody because diabetes is not costly if diagnosed and treated early, but it's very, very costly if it's left untreated. So there's an industry interest, looking upon it from our perspective: more awareness will lead to more diagnoses, which will lead to more advanced and more aggressive therapies, which leads to more business for the pharmaceutical industry. This would also reduce patients’ suffering and complications. It would help society with reduced health care costs in the long run. So I think there is legitimate interest on behalf of all stakeholders in working together.
Kelly: How has the global diabetes epidemic affected Novo Nordisk – its product line, its research and development, or its mission?
Mr. Sorensen: Therapies today are not sufficient for people with diabetes to live normal lives. So there is a lot more that we can do from the research side – there are still new drugs, and Levemir and GLP-1 therapy in particular are ways of addressing this. (Note: Liraglutide, Novo’s GLP-1 mimetic, is currently in phase 3 clinical trials. It works through the same mechanism as Amylin’s Byetta.) There are a lot of therapies that are being promoted today – DPP-4 inhibitors from Merck (Januvia) and Novartis in the future, as well (Galvus, not yet approved). These are all new therapies, including inhaled insulins, which are more convenient for the patient. And then there is still a lot that can be done in terms of developing clinical practice guidelines and dietary guidelines so our people can appropriately treat themselves. There's an amazing lot of work that can still be done.
Kelly: It’s fair to say that your biggest product, insulin, is under prescribed or under used, certainly in the US, because there're so many people who are taking it who are not at glycemic target. What do you think Novo or the other insulin companies should do to increase the use of the product?
Mr. Sorensen: It is interesting that diabetes and severe diabetes have often been associated with insulin therapy, so physicians would often encourage patients to treat themselves properly, otherwise they would be put on insulin. So historically insulin was used as a threat in some ways, and to many patients, it was viewed as the end stage of the disease. Insulin had a bad connotation. But clinical studies have shown that diabetes needs to be treated as aggressively and as early as possible, to reach near normal glycemic levels.
That is where the new therapies, like GLP-1, are important, because patients are concerned about going directly from oral agents to insulin. Insulin has traditionally had the side effects that you'd gain weight and that there may be hypoglycemia, though the latter is not very significant as it relates to type 2 diabetes - it's more significant for type 1 diabetes. So GLP-1 has presented itself recently as an intermediate step between oral therapy and insulin.
So we expect these new therapies will all find their own niche, and it's up to the physician and the patients themselves to decide how aggressively do they want to treat themselves, because we have to understand that the more aggressively the patients treat themselves, the more they infringe on their personal and private life in terms of either having to monitor blood sugar or having to take injections or multiple injections. And so it is a balance between the patient wanting to have a quality of life and the risk of developing complications long term.
Kelly: What has to happen to make diabetes the urgent issue that it should be?
Mr. Sorensen: Well, I think you're touching on a very central thing, which is also one thing that I asked President Clinton about. It's going to be interesting to see how we will make significant change unless we also look at the financing of the health care system. In my country, where we have a public health system, we view prevention and early intervention as investments – long-term investments in the future well-being of the population. Whereas in insurance-based systems, it's often difficult to see how they are able to invest, because people keep moving to different companies. And therefore the interest in investing in long-term prevention and health is significantly less. So in the US context, I think the main thing we need to get is major employers involved. We need to get the government involved because the government at the end will have the responsibility when uninsured individuals develop the complications of diabetes. And large employers will often carry the responsibility of their workforce for an extended period of time.
Kelly: Maybe you could talk a little bit about your mission to defeat diabetes and what that means to you and what you think it means to your employees.
Mr. Sorenson: Well, it comes from a simple recognition, and that is if we align ourselves with the interests of people with diabetes, they're interested in getting rid of that disease. If I could just brush aside that wish by saying it’s not technically or scientifically feasible, then we could go on selling our products. But I can't do that. We know there is scientific progress that seems to indicate there might be something we can do – stem cells and other therapies. And therefore we also have to engage in this and do our part, and as I tell my employees, it's better that we eradicate diabetes than somebody else. And we'll find another business as part of the process. Or if nothing else, we just made the final commitment to the disease. So if it can be done, it will be done.
Kelly: In light of that, what keeps you up at night? What do you worry about the most in terms of your business?
Mr. Sorensen: Well, I just spoke to a lot of our employees today [about this]. And one of the things I worry the most about is the quality of our products. We service about 15 million people with their daily needs of insulin, and if we don't make the proper quality and have the proper controls of our product, somebody is going to get hurt, and that's the worst thing … that could happen. We know there are risks involved in drug research, and that's a publicly understood risk. It's a risk that people that enter into these clinical trials understand, and they commit to that risk because they want to further research. So there are problems, of course. We try to avoid it but that's an inevitable risk we run. But not being able to supply adequate quantities of a high-quality product … could affect millions of people's lives. That's the worse fear I have.
Jim: Regarding your products, can the insulins get better than where we are now, or is it now just a matter of finding smarter ways of dosing?
Mr. Sorensen: That is the most exciting thing that right now we are working on developing yet another generation of insulins. So Levemir, when you look at it, is fantastic basal insulin, but it still has a duration of action which is slightly less than 24 hours. It has the benefit that you're not gaining as much weight as the traditional NPH or long-acting insulin. When we look at our research portfolio, we have in early research and clinical trials new and further improved basal insulins, which might even be formulated as premixes. This may not be available for another five years, but it's very, very encouraging research that we're seeing at the moment.
Kelly: This would be even beyond the rapid-acting analogs like Novolog and Humalog, like a super analog or something like that?
Mr. Sorensen: Yes. Whether we can improve it even further from that, I don't know at this point, but this will give significant benefit to those that use our products. I'm quite certain about that.
Kelly: There’s been a lot of coverage in the media about obesity as the driving force behind diabetes. What do you think can be done about that?
Mr. Sorensen: I don't believe that obesity prevention and treatment is a medical problem, in general. It's a social and cultural and societal problem that we need to deal with from a different perspective. But when we then see that there are groups of individuals having had unsuccessful attempts to diet or exercise or at counseling then we start to talk about medical intervention. And in that case, I think that perhaps GLP-1s might play a significant role in the future because we know the GLP-1 product actually reduces weight. But treating people who are just slightly overweight is absolutely not something that we want to do.
Jim: The real time bomb in diabetes is in the large developing countries like China, India, the Pacific Islands, Southeast Asia – how receptive are those countries to insulin and how much success have you had in selling your product there?
Mr. Sorensen: Very much so. It is really rewarding to come to the developing countries, because people really receive all the knowledge and all the education and all the programs that we can help them with. And of course insulinization and therapies in these countries are much less advanced than what they are in the United States and in Europe. The diagnoses rates are much, much less. People are presenting with severe complications. But it is improving. We have entered into a collaboration with the Chinese government where as part of the company's initiatives and the World Diabetes Foundation that I talked about before, we're educating 50,000 Chinese doctors in building awareness around diabetes. This is unheard of in the Western countries. People would cry, oh, foul play, how can you interact with a single industry player? They need, and they'll take, all the help they can get. Which is quite interesting, and of course very rewarding for us as a company.
Kelly: It sounds like maybe we could learn something from that in the US.
Mr. Sorensen: But it does require that the industry lives up to that obligation of having integrity and being honest and responsible. And that's where, of course, our background in some cases has been a little bit shady. And we need to regain that ground as an industry.
Jim: How has that ground been lost?
Mr. Sorensen: If you talk to the general public, the pharmaceutical industry is being viewed as self-serving and profiteering and profit-focused. But if you talk to the people that are affiliated with a specific disease and are dependent on scientific progress, I think their view is slightly more nuanced . . . To a large extent our own doing. And I'm not saying Novo Nordisk, but the industry in general, that's just something we need to recognize. So we have to work a little harder.
Kelly: Do you have any comment on inhaled insulin and what you think the prospects are?
Mr. Sorensen: Well, inhaled insulins are something we're working on as well. So far the concepts that have been presented are not really offering any clinical benefit. They are rather offering convenience for those that want to make a transition from oral therapy to insulins. And that, in itself, for some individuals represents a major hurdle and therefore should not be underestimated. But the current prototypes, if I may call the product that we have in development and that Pfizer has in promotion (Exubera), are not going to be the long-term product for pulmonary administration. We shall see whether we are able to – and Pfizer and others – are able to modernize these even further. And compared to any technological development, mobile phones or CD players or what have you, obviously they will improve and become more convenient. The question is then whether they will also be able to offer long-acting insulins in pulmonary form and therefore make a more complete portfolio of products with that administration. We might even be able to offer oral insulins, but that is still in some ways out into the future.
Kelly: Thank you so much for speaking with us and for providing so much leadership in the field.
