Good morning, Hank, it's Tuesday.

So 1.6 million people will die of tuberculosis this year, more than will die of malaria and HIV combined, which is especially infuriating because tuberculosis is curable. And there's a company you've probably never heard of called Danaher that, over the next 10 years, has the opportunity to save hundreds of thousands of lives, and I'd like all of us to encourage them to take that opportunity. So tuberculosis has killed over a billion people in the last 200 years and we've made very little progress in ending it because both testing and treatment remain out of reach for millions. Like this year, of the 10 million people who will get sick with TB, about 4 million people will go undiagnosed, often dying before they can get an accurate test. And among those who do get diagnosed, most are still diagnosed via a person looking through a microscope at a sputum sample which is precisely how we diagnosed tuberculosis 130 years ago. There are two big downsides to the microscope method. First, it misses more than 50% of cases, especially in young children and imuno-compromised people. And second, even if it finds TB, microscopy can't tell you whether a case is resistant to antibiotics, which means that many people end up on the wrong treatment regimen and commonly die before they can get on the right one. Now I know what you're thinking, "Gosh, I wish we had a miraculously fast and accurate test that could tell people not only whether they have TB, but which drugs their TB will respond to so we could immediately begin curative treatment." Well good news we do.

It's called the GeneXpert machine and it is incredible. It's made by a company called Cepheid that's owned by a larger company—Danaher—that also owns lots of other companies. And this GeneXpert machine can test not just for TB, but also for HIV, COVID, and many many other diseases. Everywhere I've traveled in high-TB burden countries, people sing the praises of this incredible GeneXpert machine. I mean, within an hour you can tell someone whether they have TB and also what course of treatment will cure their TB. Incredible, amazing, wondrous. Thank you Cepheid for building this machine. Thank you Danaher for making it all happen. There's just one problem.

As a lab tech in Sierra Leone very succinctly explained to me, "The machine is amazing. If only we could afford the tests," which brings us to the printer ink business model. Now you may know that inkjet printers are often sold at a very low profit margin because that's not actually how the companies make their money. They make their money by selling ink once you're locked into a printer, often ink that you can't buy from anywhere else. The same business model is used in disposable razor blades and also Nespresso. Like, take over the coffee market with inexpensive machines and then price gouge on the Nespresso pods. And that is what Danaher does with TB tests, and that's not like my conclusion. Their CEO Rainer Blair literally said, "These are razor blade business models in mission-critical applications," which sounds to me like the they're bragging to their shareholders about ripping off the world's poorest people.

Okay, so Danaher currently charges $10 for each of these cartridges which can detect TB and also test for resistance to a common first-line antibiotic. And they also make another cartridge that tests for resistance to four more anti-TB drugs. For that one they charge not $10, but $15, which is frustrating because one, we really need to identify extensively drug resistant tuberculosis quickly and accurately to prevent its further spread. And also two, it doesn't cost Danaher more to make those cartridges than the regular ones. All the cartridges cost them about the same to make. So how much should these cartridges cost? Well Danaher has refused to share any of their cost information with global health authorities but in 2019, Doctors Without Borders commissioned a study asking a group to look at how much it cost to make these. And what they found is that it cost somewhere between $3 and $4.50. The same is true for all of Danahher's test cartridges regardless of whether they're testing for TB or XDR TB or HIV or anything else. Based on that study, Danaher is charging at least a 220% profit margin for their regular TB cartridges and closer to a 500% profit margin for their extensively drug-resistant cartridges, which in my opinion is just unconscionable.

And I apologize if I sound angry, but I've known so many people who went undiagnosed for months or even for years, and some of those people have died. And so I am angry. They died because they couldn't get an accurate test in time and I simply don't believe that Danaher charging these profit margins is making it easier for anyone who needs the test to be able to access it. Instead, they are overcharging poor countries for tests and preventing competition by locking people into their machines with that printer ink business model they love to boast about. Also, in developing these tests, Danaher received over $250 million of public funding, most of which came from taxpayers like me and you. And I think it's past time for Danaher's prices to acknowledge that GeneXpert tests are public goods largely funded by the public and that it isn't appropriate to use them to enrich the world's richest people at the expense of the world's poorest ones.

Since 2019, Partners in Health, Doctors Without Borders, and a huge array of other organizations have been trying to convince Danaher to consider lowering their prices to $5 per test cartridge, which would be a healthy profit margin instead of an obscene one. They've written open and closed letters, Cepheid and Danaher haven't responded. They've lobbied for $5 tests in public meetings, Cepheid and Danaher haven't responded. And so now, they've asked us to join them in taking the next step on that journey. Now look, Danaher is a company with $8 billion in profit. They are not hurting. But it's a little hard to put pressure on them because they they don't own a lot of consumer facing stuff. Although they do weirdly own, of all things, Pantone, the color matching company. They're currently in the process of spinning it off into another company, but Danaher shareholders will still be Pantone shareholders so maybe there's some pressure to apply there.

But mostly, I think it's important for Danaher to know that this is just a bad business decision. It's important for them to know that we are paying attention and will continue to pay attention. And we will endeavor to make it cost more to their reputation and their ability to recruit and do business than the infinitesimal hit to their profit that would accompany $5 tests. So that's where you come in. If you have 5 minutes to make a phone call or write an email, there are links below and in the pinned comment. Also please let Danahher know on social media that you will not accept this injustice. They're on Twitter and Facebook and Instagram and Threads, and Hank and I will be in all of those places amplifying your messages. And if you happen to work at Cepheid, which makes the cartridges, or Danaher, which makes the decisions, let your bosses know that you're not okay with this. I know that takes a lot of guts, but I also know it was an essential part of the pressure on Johnson & Johnson that led to them swiftly announcing they would allow generic competition for their drug bedaquiline.

Lowering the prices of these tests to $5 would likely save hundreds of thousands of lives over the next 10 years. And I am disappointed that Danaher is currently choosing profits over people, but I don't think it's inevitable. I think that most people most of the time want to do what is right. They just sometimes need polite but impassioned reminders of what's right. I know that I've benefited from those polite but impassioned reminders from others, even when they've made me uncomfortable, and I believe that Cepheid, Danaher, and their executives will similarly benefit from your polite but impassioned reminders.

Finally, a message to Danaher execs. You've built something amazing with the GeneXpert machine, but building something is only valuable if the people who need it most can access it. Right now, you're falling short on that front because the people who most desperately need your tests often can't get them, and that results too often in them dying. It's time for $5 tests and it's time to put people over profits.

Hank, I'll see you in comments, on social media, in Danaher's inboxes, and their phone lines, and then, I'll see you on Friday.