Isati yagadzirwa nzira yekubvisa insulin kubva pancreas yemhuka muna 1921, vana vane chirwere cheshuga vaiwanzofa mukati megore rekuongororwa. Waive mutongo werufu.
Uye saka kuwanikwa kuYunivhesiti yeToronto nesainzi Frederick Banting kunofanirwa kukwenenzverwa seimwe yebudiriro huru yezvekurapa yezana ramakore rechimakumi maviri, rinenge remashiripiti musimba rayo rekushandura. Vanachiremba vepayunivhesiti vakatsanangura kuchinja kwerombo sechinhu chinobva mungano: “Varwere . . . vakaunzwa muwadhi yekukurumidzira, vasina chavanoziva vari muchirwere cheshuga, [uye] pavakabayiwa jekiseni re insulin vakamuka zvinoshamisa, vakabvutwa pamusuwo werufu, "akadaro Bill Bigelow, chiremba wechidiki wepayunivhesiti uye anopupurira kumiyedzo yekutanga yekubvisa mahormone.
Makore maviri gare gare Banting nevamwe vake, Charles Best naJames Collip, vakapihwa US patent ye insulin. Vakaitengesa kuyunivhesiti ne $ 1 chete, uye Banting akaramba kuisa zita rake patent. Kuti chiremba awane purofiti kubva mukupindira kwekurapa kwakakosha kungave kusina kunaka, akatenda kudaro.
Asi nhasi, mutengo wakakwira zvakanyanya muUnited States - inodarika mazana matatu emadhora pavharo, kana kupfuura $300 pamwedzi kune vamwe kana vasina inishuwarenzi yehutano yakakwana, kubva ku21 muna 1999 - kuti mumwe muvanhu vana vekuAmerica vane chirwere cheshuga vanofanira kugovera insulin yavo. Chirwere cheshuga chakwira pachinzvimbo chechinomwe uye ndicho chinokonzeresa kutadza kwechiropa, kudimburwa maoko nemakumbo, uye upofu. Izvo zvakare zvinowedzera njodzi yekufa kubva kuchirwere chemoyo, sitiroko, gomarara, uye hutachiona, kusanganisira kubva kuCOVID-19. Senator Bernie Sanders ane mukurumbira vakatora varairidzi yevarwere mhiri kwemuganhu weCanada kuti vatenge iwo mabhodhoro e insulin chete nemadhora makumi matatu nemaviri.
Kubatsira kubva kumafemu matatu ane chekuita nekugadzirwa kwe insulin muUnited States - uye kubva kune vamwe vatambi vanofambiswa nemusika muAmerican health care system - kwave kunyanyisa, uye kukuvadza kwakanyanya, zvekuti hurumende dzeCalifornia, Maine, uye Michigan ikozvino yave kutarisa kugadzira yavo insulin. MuMichigan, murume ari kutungamira mhosva yeiyi "insulin socialism" anotova muRepublican.
Iyi ndiyo ngano yekuti takasvika sei panguva ino, uye kuti zvirevo zvakadaro zve "People's Insulin" hazvigone chete kugadzirisa dambudziko re insulin, asi - kana rikaurayiwa zvine hungwaru - vhura musuwo wekumutsidzira hukuru, hurefu- nguva yekudyara kweruzhinji, kuronga kwehupfumi, uye demokrasi yemagariro muzana ramakore rechimakumi maviri nerimwe.
Insulin haina kufanana nemimwe mishonga
Yunivhesiti yeToronto yunivhesiti, kwete nzvimbo yekugadzira makemikari. Saka mushure mekuwanikwa kwaBanting, vakatendeukira kuConnaught Laboratories (yakavambwa muna 1914 kuti igadzire diphtheria antitoxin yakawanda) kugadzira insulin muCanada. Connaught aive nebasa rekuti mushonga urambe uchiwaniswa, uye akaita kuti insulin iri muripo.
KuUnited States, Yunivhesiti yeToronto yakatendeukira kuna Eli Lilly, kambani yekuAmerica inoita purofiti yekugadzira mishonga yemakemikari. Mukuchinjana kwegore rimwe chete rekugovera monopoly, Eli Lilly aizogadzira mushonga. Muna 1923, yakava chigadzirwa chakatengeswa zvakanyanya munhoroondo yekambani, ichigadzira purofiti yakaenzana neinopfuura hafu yemari yayo.
Kazhinji nekufamba kwenguva, mutengo wemishonga unodzikira sezvo hupfumi hwakazvimirira hwepamatendi hunopera uye vagadziri vemakopi akachipa, egeneric vanodzikisa mutengo pasi. Izvo hazvina kuitika ne insulin, kunyangwe mushure memakore angangoita zana ekugadzirwa.
Kuti tinzwisise kuti sei, isu tinofanirwa kutora kapfupi kutenderera kuti tinzwisise kuti insulin chii uye kuti inoshanda sei.
Insulin chinhu chinogadzirwa mukupindura chikafu neasinganzwisisike anonzi "islets of Langerhans" - masumbu emaseru eendocrine (anogadzira mahormone) mumarwatata ako. Inobvumira glucose kupinda mumasero emuviri wako uye kuishandisa sesimba, uye inoudza muviri wako kuchengetedza chero glucose yakasara (shuga) muchiropa chako. Muchidimbu, insulin inogadzirisa huwandu hweglucose muropa rako.
Kana muviri wako usingakwanise kugadzira insulini zvakanaka (rudzi rwe 1 chirwere cheshuga), kana insulin isingashande sezvainofanira kuita kana kuti haugone kuigadzira yakakwana (rudzi rwechipiri), shuga yako yemuropa haichatarisirwi zvakanaka. Haisi chete muviri wako unoda glucose yesimba (saka kuneta uye nzara yakanyanyisa iyo inowanzova zviratidzo zvechirwere), yakawandisa muropa inogona kukuvadza tsinga dzeropa, nhengo, uye tsinga (saka kukundikana kwechiropa, sitiroko, moyo. chirwere, uye kuchekwa).
Ikoko mishonga mizhinji kazhinji iri nyore, mamorekuru madiki anogadzirwa kuburikidza neakatwasuka kemikari maitiro, insulin ndiyo protein hormone. Mapuroteni akakura kwazvo, akaomarara, haasi mamorekuru akareruka, anogadzirwa nemasero mapenyu - kana iri insulin, nemasero e beta muzvitsuwa zveLangherans. Rangarira kuti insulin yakatanga kugadzirwa nekuibvisa kubva pancreas yemhuka: mangwanani-ngwanani kubva kumbwa, uye nguva pfupi yakatevera kubva kumombe nenguruve. (Insulin yakabva kumhuka haichatengeswa muUnited States.)
Kugadzirwa kwe munhu insulins nhasi inosanganisira genetically engineering E. coli mabhakitiriya kuitira kuti ave nejini rekugadzirwa kwe insulin yemunhu, uyezve kuendesa mabhakitiriya aya semafekitori e insulin. Chekupedzisira, kune zvakare insulin analogues, iyo inogadzirwa nekugadzira, uye inoshandurwa kushandura chiyero icho muviri wako unotora mu insulin. Izvi zvinonyanya kutaurwa uye zvinogona kuita kuti zvive nyore kune vanhu vane chirwere kuronga kudya kwavo.
Izvo zvese izvi maitiro ekugadzira akafanana ndezvekuti anodzokorora maitiro akaomarara ekugadzira zvinhu zvipenyu, kazhinji achishandisa zvipenyu kana masero azvo se "nzvimbo dzinobereka." Kureva, ivo "biologic mishonga," kana kungoti "biologicals." (Mamwe biologics anosanganisira kukura kwehomoni, masoja ekudzivirira chirwere, uye mamwe marapirwo eArthritis.)
Iko kuoma kwakaoma kwekugadzirwa kwe insulin kunoita kuti zvisashande mune zvemari kumakambani emishonga yemagetsi. Saka, pachinzvimbo chejeneric insulin, tinotaura nezvayo biosimilar insulin - mushonga webiosimilar biologic, kana "biosimilar," mushonga webiologic wakafanana zvakanyanya asi usina kufanana nepakutanga. Mishonga yeGeneric yakafanana nemakopi epakutanga asi biosimilars haisi nekuti chimiro chekupedzisira (uye icho chepakutanga biologic mushonga uyo biosimilar iri kutevedzera) zvinoenderana nekugadzira maitiro zvakanyanya kupfuura zvekutanga.
Kunyange iyo nzira yese yekugadzira insulin iri ruzivo rweveruzhinji, iyo chaiyo yekugadzira maitiro ndeye kutengeserana chakavanzika, chimiro chehungwaru pfuma isina zuva rekupera.
Nekuda kweizvozvo, kambani yebiosimilar inofanirwa kushandisa mari yakawanda kuti igadzirise yakazvimirira iyi nzira yekugadzira. Mari inofungidzirwa yekudyara kweiyo biosimilar imadhora zana nemakumi maviri nemakumi mashanu emamiriyoni pamakore manomwe kusvika masere, zvichienzaniswa nemadhora 100-250 miriyoni pagore rimwe chete kune madiki-morekuru generic mishonga.
Saka hechino chakakosha: nepo biosimilars ichichipa zvishoma pane yepakutanga biologic, isu hationi mutengo uchidzikira uchienzaniswa nekambani yemishonga yegeneric inokopa fomula, toti, aspirin. Iyi biological chimiro chemushonga uye chokwadi chekuti nzira yekugadzira inonakidzwa nekutengeserana zvakavanzika kuchengetedzwa inotsanangura kuti nei pasina kukwikwidza kwakawanda mukugadzirwa kwe insulin (kana kune iyo nyaya, mukati mekugadzirwa kwemamwe biologics). Vazhinji vevagadziri vepasi rose ve biosimilar insulins makambani ayo kare gadzira insulini - nekuti vanogona kutsamira paruzivo rwavo uye tekinoroji uye havafanirwe kudzoreredza vhiri sezvinoita vakwikwidzi vechokwadi.
Pamusoro pezvo, nemishonga yakajairwa-mamorekuru, makambani emishonga anogara achichinja mamorekuru ari muzvigadzirwa zvavo zvishoma, achiavandudza zvine mwero, obva aapazve mvumo kuti aedze kuramba ari pamberi pevanokwikwidza. Iyi tsika ye "evergreening" inoitwa zvakanyanya kuipa kune zvigadzirwa zve insulin uye avo vanogona kukwikwidza biosimilar nekuoma kwekugadzirwa kwebiologic.
Zvose izvi zvinotsanangura kuti sei dambudziko reinsulin reUnited States risiri chiitiko cheAmerica chete. Europe haina kubudirira zvakanyanya kuyedza kukwezva mafemu kuti agadzire ma biosimilars.
Asi kukakavara hakugumiri ipapo. Kubatanidza iyi biochemical, dhizaini, uye yekugadzira dambudziko, mazhinji emapeni uye mamwe maturusi anoshandiswa kuendesa insulin - zvishandiso zvakasungirirwa kune imwe mhando uye mhando ye insulin - inotakura yavo patent. Anogona biosimilar kuvandudza saka wo vanofanira kugadzira midziyo yavo yekuendesa, asi chimwe chipingamupinyi kupinda mumusika.
Chekupedzisira, nepo biosimilars isingatarisirwe, misiyano ine musoro mukubudirira kana kuchengetedzwa, nekuti yakafanana haina kufanana, inoiswa kune dzimwe dzidzo isati yawana mvumo yekutonga. Kusiyana nemagenerics, mabiosimilars haangogone kutsiva epakutanga. Vanofanira kuratidza kuti vanogadzira mhedzisiro yekiriniki imwechete uye havaise njodzi huru. Izvi zvidzidzo zvekuwedzera uye matanho emvumo zvinowedzera kuwedzera mutengo. Nekuda kweizvozvo, kunyangwe inoyemurika gadziriso yezvivakwa - sekubvumidza kushoma kuburitswa kwemaitiro ekugadzira uye kumisikidzwa kwemidziyo - yaizongodzikisa zvine mwero dambudziko rekutenderera kwemutengo.
Imwe nzira yekurwisa iyo inonyanya kukosha - chimiro chebhayoloji yemushonga - ingave yekurerutsira kubvumidzwa kwekuchinjana kwekutanga biologic drug uye biosimilars. Izvi zvakaitika kune dzimwe nzvimbo, uye muna 2020, iyo US Food and Drug Administration (FDA) yakaburitsa zvimwe. nhungamiro itsva uine chinangwa ichi mupfungwa uchibvumirawo yayo yekutanga biosimilar, Semglee, yakareba-inoshanda insulin analogue inogadzirwa nemakambani emishonga Biocon uye Viatris inotevedzera Sanofi's Lantus insulin chigadzirwa. Zvino muna Chikunguru 2021, iyo FDA yakapihwa zita rayo rekutanga-kuchinjana kuSemglee.
Zvakadaro, ma biosimilars anowanzo kuburitsa mutengo kudzikiswa kweanosvika gumi neshanu muzana, zvichienzaniswa ne15-50 muzana yemageneric. Sanofi's Lantus inoita madhora mazana maviri nemakumi masere neshanu pabhodhoro, kana madhora mazana mana nemakumi maviri neshanu pabhokisi rezvinyoreso zvishanu, ukuwo mutengo wekutanga wemutengo weSemglee usina kudhindwa unongori madhora makumi mapfumbamwe nemapfumbamwe pabhodhoro, kana $80 pamapeni mashanu - donho rakacherechedzwa, asi richiri rakakwirira kudarika. muCanada. Viatris yakatengesa Semglee pane imwechete sticker tag seLantus pens muna 280, uye Lantus insulin vials muna 425. Vavariro yavo ndevaya vasina inishuwarenzi kana vane mari yakawanda inobviswa vanoda kubhadhara insulin yavo mumari.
Iyo Manchin Mhuri Maneuver
Chiito chaViatris pa insulin igadziriso yechokwadi, inogoneswa neiyo FDA's smart intervention kusimudzira pathology yemusika maitiro.
Asi ndiani Viatris? Sei vari kupinda mumutambo? Zvinosetsa unofanira kubvunza.
Viatris izita idzva reiyo firm Mylan, yaungarangarira sevagadziri veEpiPen - epinephrine auto-injection iyo vazhinji vanorwara nechirwere chekudya vanotsamira pakurapa zviitiko zveanaphylactic shock. Mylan akakwidza mutengo wemapaketi maviri eEpiPens kubva pamadhora zana nemakumi maviri nemana muna 124 kusvika pamadhora mazana matanhatu nemakumi mapfumbamwe muna 2009, zvichikonzera kuchema chema kweveruzhinji izvo zvakamanikidza kambani iyi kuti ibudise imwe generic imwe neimwe ine yakaderera (asi ichiri kunyomba) tikiti remutengo wemadhora mazana matatu.
Mylan, uyo aidzora 96 muzana yemusika weUS we epinephrine auto-injection, akakwanisa kuita mashenanigans aya nekubatana naPfizer, muridzi weEpiPen's competitor, Adrenaclick. Pfizer akabvisa Adrenaclick pamusika, achiendesa monopoly kuMylan, mukudzorera kuderedzwa kwemitengo-inokwira, izvo zvaizobvumira Pfizer kuwana mari yakawanda kupfuura yaaizoita nekugadzira anokwikwidza akachipa. (Sezvineiwo, pamusoro peichi chiitiko-chinokwira mutengo, Mylan aive pakati pevapi vahombe kumushandirapamwe weDemocratic senator Joe Manchin, anove zvakare baba veMylan's CEO, Heather Bresch. Sezvo Bvisa kwakaratidza gore rapfuura, amai vake, Gayle Manchin, uyo panguva iyoyo aiva mukuru weNational Association of State Boards of Education, vakakurudzira nyika kuti dzimanikidze zvikoro kuti zvitengese zvinhu zvinoponesa upenyu zvemwanasikana wavo uye, zvinodhura zvikuru, zvekutengesa.)
Mylan akazoregedza zita rake rakashata. Kugadzira Semglee imwe nzira yekugezesa mhando yayo inotyisa. Uye Mylan/Viatris anokwanisa kuzviita asi asiri kunyatsorasikirwa ne insulin bonanza: Semglee anouyawo mune yakasarudzika vhezheni, yakanangana nemainshurensi nemamaneja emushonga wezvemishonga (zvimwe pamusoro peava vepakati uye chidimbu chakasiyana chehudhiyabhorosi chavanokwira nacho United States munguva pfupi pfupi) pamadhora mazana maviri nemakumi manomwe pabhodhoro, kana madhora mazana mana emapeni mashanu. Izvi zvichiri kuguma zvichidhura hurongwa hweUS zvakanyanya kudarika dzimwe nyika dzinoshandisa.
Uye kunyange iyo $99 isina bhaisikopo yeSemglee - inokwana kwemazuva mashoma kusvika kumavhiki kune vamwe - ndeyekubvarura. A 2018 ongororo yemitengo yekuisa uye yekugadzira maitiro ekugadzirwa kwe insulin inoonekwa mu British Medical Journal muna 2018 yakaratidza kuti kurapwa ne insulin analogues senge Lantus kana Semglee kunogona kuita $133 kana zvishoma. gore negore.
Uye zvese izvi sarudzo - kukurumidza kubvumidzwa kwebiosimilar, kurerutsa kuchinjika, kuburitswa pachena kwekutengeserana, kumiswa kwemidziyo - kwaizomutsa kupikisa kwakasimba kubva kune vatatu vakuru vanogadzira insulin: Eli Lilly, Sanofi, uye Novo Nordisk yeDenmark, iyo inodzora musika weUS insulin. uye 90 muzana yemusika wepasi rose.
Kunyangwe nehukasha hwekutemerwa kwevanopesana nekutenda, zvipingamupinyi zvekupinda nekuda kwechimiro chebiologic chemushonga zvichiri kuwanda uye kutonga kwavepo kwemusika kwakaringana, zvekuti mamwe mafemu anogona kuregedzerwa kunyange kuedza. Vaive mukwikwidzi mutsva, wakavanzika webiosimilar kuyedza kuzvisimbisa muUnited States, kana chero kupi zvako, Iwo Big Three aigona kudzikisa mitengo yavo kwenguva pfupi uye kudzikisa kumusoro. Merck uye Samsung Bioepis vakasiya kupinda kwavo mumusika weUS nechikonzero ichi chete, uye Novo Nordisk yakapawo mutengo kunze kwevakwikwidzi veIndia. Sezvo Yale hutano mutemo nyanzvi Ryan Knox akanyora muna 2021 tsananguro nezvedambudziko racho: “Kubata kweBig Three pamusika wepasi rose we insulin kunoita kuti pasave nechokwadi kana ‘zviine mari’ kuti vagadziri vatsva vebiosimilar vapinde mumusika . . . [e] kunyangwe insulin yaigona kutengeswa nemitengo yakaderera uye ichiri kupa pundutso.
Walmart kune Kununura?
Muna Chikunguru 2021, Walmart yakatangwa yayo pachayo mhando yekukurumidza-inoita insulin analogue, NovoLog, sechikamu cheiyo ReliOn suite yezvigadzirwa zvehutano. Mutengo weti: $73 pa vial.
"Murwere akajairwa anoshandisa mabhodhoro maviri ekukurumidza kuita insulin pamwedzi anoshandisa $1,749 pagore yeWalmart's ReliOn Novolog," akadaro Hilary Koch, maneja weboka rinomiririra chirwere cheshuga T1Interational (iyo, kusiyana nemapoka mazhinji ekutsigira varwere, inoramba mari kubva kuBig. Pharma). "Kunyange iri pasi pemutengo wakazara we $6,945, uyu uchiri mutengo wakakwira wemushonga unokosha."
Kana tichienzanisa, mutengo wetikiti i$6-13 pabhodhoro payasara yese yeOECD (Sangano reKudyidzana Kwehupfumi neBudiriro, kirabhu yenyika dzakasimukira), uye mutengo wekugadzira nekuunza kumusika nekukurumidza-inoita analogue insulin. $6-7 per vial.
Uye zvakare, iyo ReliOn insulin inopfeka yakavanzika label yeWalmart, asi inogadzirirwa chitoro naNovo Nordisk, imwe ye insulin Big Three. Ko Novo Nordisk yafunga kubva muzvakanaka zvemoyo wayo kusiya pane yakakura mari?
Hazvigoneki. Sezvinoonekwa nemutambo weMylan/Viatris, nzira yakajairika yemafemu ezvemishonga inotariswa neveruzhinji ndeyekuparadzanisa chikamu chemari yakaderera chemusika, kungave kuburikidza nenzira-yakaedzwa kudzoserwa kana shanduro yakachipa inotengeswa munzvimbo iyoyo. Novo Nordisk inogona kunge ichitarisira kuti nekumedza kurasikirwa uku, vezvematongerwo enyika uye vezvenhau vachadaidza imbwa uye vovatendera kuti varambe vachikunguruka muhupfu muzvikamu zvinobhadhara zvemusika.
Asi kunyangwe pano, zvicharamba zvichionekwa kuti Sanofi naEli Lilly vachaita sei kuNovo Nordisk-Walmart gambit, kana kuti, sekutamba neimwe yeBig Pharma mhuka, ivo vanongovadzikisira kwechinguva kuvamanikidza kubvisa yavo. chigadzirwa.
T1International haisi kutora chero mukana: yadaidzira kuunzwa kwemubatanidzwa mutengo chivharo pane kuenderana nerupo rwekufungidzira rweWalmart neNovo Nordisk.
White-Hatted Capitalist Charity
Mutambo uchangoburwa unonakidza wakabva kuCivica Rx, mubatanidzwa wevanopa philanthropists, vanopa hutano, uye mainishuwarenzi. Kunyange ichisanganisira masangano asingabatsiri uye anoita purofiti (kusanganisira Blue Cross Blue Shield naKaiser Permanente), iyo Utah-based consortium yese haizi yepurofiti, uye inotogadzira mamwe makumi matanhatu akasiyana emishonga. Muna Kurume 2022, Civica yakazivisa kuti vaizogadzira uye kugovera matatu akasiyana ma insulin biosimilars vasingatarise purofiti, zvese zvisingapfuure madhora makumi matatu pabhodhoro kana madhora makumi mashanu nebhokisi remapeni mashanu. Sezvambotaurwa, ma biosimilars anowanzo kutora makore mazhinji kusati kwave kuwanikwa kwekutengesa, uye Civica Rx akabvuma zvipingaidzo zviri pamberi pavo achiisa zuva rekuburitsa 30.
Civica inofanirwa kuombera maoko, asi chikonzero chekuvhiyiwa, sekubvuma kunoita webhusaiti yeboka, kuendesa mamirioni emadhora mukuchengetedza kuhurongwa hwechipatara chemubatanidzwa, zvese zvisiri zve-purofiti uye zvakavanzika. Chinangwa ndecheku "gadzira kugadzikana kwemusika" uye "kuvimbisa mavhoriyamu" kune avo vavanoda. Iko kukwira kwemutengo we insulins (nemimwe mishonga) haina kungoipa kune varwere; hazvina kunaka kuzvipatara nemainishuwarenzi zvakare. Civica's yerudo yekuedza saka zvakare ingori ine musoro bhizinesi sarudzo. Uye kana varwere vari nani somugumisiro weboka rimwe remacapitalist vanogumburwa neimwe seti yecapitalist, zvine basa chaizvoizvo here kuti vokutanga vari kungozviita nokuda kwechikonzero chaichoicho?
Kwete chaizvo, kwete. Asi izvi zvine simba zvakare zvinoreva kuti kana chero nguva kuedza kwavo kuchirega kuve sarudzo ine musoro yebhizinesi - kana Big Three vakashandisa simba ravo remusika uye vakashandisa hunhu hwakasiyana hwekugadzirwa kwe insulin kuisa pakusvinwa, uye hazvichafariri. ye "white-hatted" capitalists muCivica consortium - ipapo ivo vangangobuda.
Izvi zvinogona kutsanangura chikonzero nei gavhuna weCalifornia Gavin Newsom - aive nazvo zvakambofungwa Kudyidzana naCivica Rx pajenariki uye insulin biosimilars - uye Maine neMichigan vakasarudza kusundira kunze kwavo. Uye hapana kukuvadza mune zvese sarudzo yeruzhinji uye sarudzo yerudo inoshanda zvakasiyana (kana kujoinha mauto) kudzikisa mitengo.
The Dastardly Middlemen
Kupfuura hunhu hwakasiyana hwekugadzirwa kwebiological ye insulin, kune zvakare imwe yakasarudzika sosi yekuAmerica mumusanganiswa inoita kuti mamiriro acho anyanye kushata kana achienzaniswa nekumwe kumwe: makambani ekutonga emishonga (PBMs kana vatariri vezve pharmacy).
PBMs makambani akazvimirira muUS health care ecosystem anoita sevamiriri pakati pevagadziri vezvinodhaka, mainishuwarenzi, uye ma pharmacy. Zvitatu zvinotonga chikamu ichi: CVS Caremark, inotsigira CVS zvitoro zvemishonga; Express Scripts; uye OptumRx. Mainishuwarenzi anobvumirana nePBMs kubata nhaurirano pamusoro pemitengo yezvinodhaka nevagadziri, pamwe nekubata zvichemo zveinishuwarenzi uye kugovera mishonga. Pfungwa yepakutanga yePBM yaive yekutora mukana wesimba rekutenga rakaunganidzwa remakambani einishuwarenzi evatengi vavo kuti vatsigire mutengo wezvinodhaka.
Hazvina kushanda sezvakarongwa.
Vagadziri vezvinodhaka vanorasikirwa nemachunks makuru emusika mukuru wemishonga weUS kana zvigadzirwa zvavo zvikasaguma pa "mafomula" - rondedzero yemishonga inozovharwa nehurongwa hweinishuwarenzi yehutano. Ndiani anosvika pakusarudza kuti ndeapi mishonga ichaonekwa pamaformularies? Iwe wakazvifungidzira: maPBM.
Kuti varambe vari munyasha dzevachengeti vemagedhi vePBM, vagadziri vezvinodhaka vanobhadhara maPBM makickback ayo avanodaidza kuti "kudzoserwa kwevagadziri." Zvidzoreso, izvo zvinoverengerwa sechikamu che "mutengo" wemushonga (aka mutengo wekunamirwa), inova nechokwadi chekuti maPBM anounza nzvimbo yakasarudzika pamafomu emushonga wemugadziri: "Une mushonga wakanaka ipapo, Larry. Zvingave zvinonyadzisa kana, iwe unoziva, yakadonha kubva pafomulary. "
Kuvhara mutengo wechiokomuhomwe ichi - sorry, rebate! - vagadziri vanongokwidza mutengo wemapepa. Izvi zvinoitika nemishonga yese, asi seSeneti yeUS ripoti vakawana, mamiriro e insulin akanyanya kuipa. MaPBM anoita kuti chinhu chinodhura chitonyanya kudhura. Sekureva kwemutungamiri weEli Lilly, mutengo wekuderedzwa unoumba 75 muzana yemutengo wakanyorwa wezvigadzirwa zveinsulin zvekambani.
Isu tinowanzo chema villainy yeBig Pharma, asi isu tinogona zvakare kuda kupa fungidziro diki yehunyengeri hwevasina mumvuri, vePBMs, vanoshanda kunze kwemaonero evanotonga, vatengi, uye vezvenhau, uye vanounza zvinopfuura. $200 bhiriyoni pagore kubata masevhisi ekurapa kune inshuwarisi. PBMs chimwe chezvikonzero zvekuti nepo United States inomiririra 15 muzana chete yemusika wepasi rose we insulin, ine chekuita nehafu yemari yese kubva kune insulin.
MaPBM akashata, zvekuti, maDemocrats nemaRepublicans vava kutarisa kuvakanganisa. Muna Chivabvu, senator weRepublican Charles Grassley akabatana neDemocratic senator Maria Cantwell ku suma mutemo kupa simba kuFederal Trade Commission nemagweta ehurumende kuti vatevere “zvisina kunaka nekunyengera” PBM maitiro anokwidza mitengo yezvinodhaka. Mamwe maseneta eRepublican, anosanganisira Jeanne Shaheen weNew Hampshire naSusan Collins weMaine, vari kutsigira mutemo unobvisa PBM insulin.
Asi usafunge kuti maoko evanogadzira zvinodhaka akachena. Muna Chivabvu 2017, nyaya yakamhan'arwa mudare remubatanidzwa reLos Angeles ichiti imwe ye insulin Big Three, Novo Nordisk, yakabatana nePBM OptumRx mu "chirongwa chemitengo isiri pamutemo" kukwidza mutengo weVictoza, mushonga wechirwere cheshuga (kwete insulin, asi mushonga unobatanidza werudzi rwechipiri chirwere cheshuga chinobatsira kudzora shuga yeropa).
Uye kunyangwe kukoromoka kwePBM kwakabudirira, hazvigadzirise dambudziko rakadzama rinobva kune zvakakosha zve insulin.
Sarudzo yeCanada
Insulin yakasarudzika hunhu yakaita kuti vamwe varapi, vemakemikari, uye vakuru vehutano hweveruzhinji kuti dana mushonga kuti a natural monopoly. "Kusiyana nemamorekuru madiki anopihwa masimba ekugadzira, biologics inotsanangurwa zvakanyanya seyakasikwa monopolies," quartet yenyanzvi dzekiriniki yakanyora mu. Health Health gore rapera. “Vanodzivirirwa nezvipingamupinyi kuti vapinde zvinobva mukusava nechokwadi kwesayenzi kunobva mukuoma kunzwisisa kwavo; zvipingamupinyi izvi zvinodhura, zvinodya nguva uye zvine njodzi kutyora. "
Sekuzvitonga kwega, vanopokana, insulin inoda imwe nzira yekudzora mutengo kudzivirira vanogadzira kubva kubhadharisa chero chavanoda. Izvi zvinogona kutora mafomu akati wandei. MaCenter for Medicare neMedicaid masevhisi anogona kuramba kubhadhara mutengo wepamusoro weakatanga mishonga uye kungotenga biosimilars. Secretary of Health and Human Services anogona kutaurirana nezvemitengo yezvinodhaka akamiririra vese vekuAmerica. Panogona kuve nemiganhu pamitengo inobvumidza mutengo wekugadzira pamwe nekuwedzera kumusoro, kana mitengo inopa kudzoserwa kudzoreredzwa pakudyara kana imwe maringe yakatsanangurwa. Mune mamwe mazwi, kutonga kwemitengo.
Aya ese mazano ekugadzira. Uye hazvisi zvidzoreso zvemitengo kuti Canada inochengeta sei insulini mutengo wakaderera kupfuura iyo US zvakadaro? Icho chokwadi chikamu chenyaya.
Muna 1987, paramende yeCanada yakagadzira Patented Medicine Prices Review Board, dare redzimhosva iro rakapa makambani emishonga quid pro quo: tinokupa yakawedzera dziviriro patent, uye unobvuma kutungamira kudzorwa kwemitengo yemishonga yako. Bhodhi remitengo rinoisa mutengo wakakura kwazvo mushure mekutarisa mutengo wepakati webhasiketi renyika gumi neimwe dzakaenzaniswa muEurope pamwe neJapan neAustralia (United States yaimbova muenzanisi zvakare, asi ichangobva kuderedzwa nekuda kwemitengo yayo yekunze inotsvedza pakati peavhareji. )
Pamusoro peizvi, hurumende yemubatanidzwa yeCanada nemapurovhinzi vanoshandisa simba ravo rekutenga pamwe chete kutaurirana mutengo wemushonga wakatodzika. Chinangwa chekupedzisira - chiri pabepa - kugadzira chirongwa chepasi rose chemishonga chinoputira mishonga muCanada-single-payer health care system (kunyangwe paine kurwa kukuru kumberi kuti hondo iyoyo ikundwe).
Makambani emishonga anogara achichema kuti mutemo wemitengo weCanada-maitiro unotadzisa hunyanzvi, asi chirevo cha2021 US House. akawanikwa kuti Novo Nordisk, semuenzaniso, yakashandisa yakawanda mukutenga masheya uye mubhadharo wekugovera pane pakutsvaga nekusimudzira mune rimwe nerimwe remakore mashanu apfuura.
Saka nzira yekudzora mutengo ingashanda muUnited States here?
Iyo California Option
Dzimwe nyika dzakabvisa kunze-kwe-homwe insulin mari kune avo vane inishuwarenzi. Nevada yakaraira insulin yemitengo pachena muna 2017, uye makore maviri gare gare Colorado yakava nyika yekutanga kumisa mutengo chaiwo we insulin. Muna Kubvumbi, House Democrats yakakwanisa kupasa Inotengeswa Insulin Zvino Act nerubatsiro rwegumi nevaviri maRepublican. Chiitiko ichi chaizovhara mutengo we insulin pamadhora makumi matatu nemashanu pamwedzi - zvakare, kune avo vane inishuwarenzi, uye inogona kubvumira Medicare kutaurirana zvakananga mutengo we insulin nevanogadzira zvinodhaka, zvakafanana neCanada system. (Bhiri, ikozvino akaputirwa mukati iyo omnibus Inflation Reduction Act, ichiri kufanira kupasa Seneti.)
Hapana, zvisinei, ari kuvhara mutengo we insulin kune vasina kuvimbiswa.
Nekudaro, nekuda kwekusagadzikana kwehurongwa hwezvematongerwo enyika hweUS, nhanho-yepamusoro "insulin socialism" - hurumende inogadzira mushonga wacho - inogona kunge iri nyore kuwana pane nzira inoratidzika kunge ine mwero uye isina kupindira yekuyambuka-iyo-bhodhi mutengo wemutemo. . Zvisineyi, zvinonyatso zadzisa zvivharo zvemitengo, kurwisa dambudziko re insulin kubva kune rumwe rutivi. Inofanirawo kutyaira mitengo yakaderera zvakadaro, pamwe nekuwedzera kugovera uye kudzivirira kutamiswa kwedambudziko kune dzimwe nyika sezvo Big Three kuedza kudzoreredza kurasikirwa kupi zvako muUnited States nekudzvanya mamwe masimba.
Uye pakupedzisira mutengo zvivharo, sezvingave zvichidikanwa, matanho ekumisa. Canada inogona kunge iine mutengo wekudzora, asi mitengo iri kukwira ipapo. A 2016 ongororo nebhodhi rekuongorora mitengo yenyika rakaona kuti kubva muna 2010 kusvika 2015 mutengo weavhareji we insulin wakakwira kupfuura 50 muzana, pamusoro peinflation. Kukwira kwemitengo kwemamwe mishonga muCanada panguva imwe chete kwakagara munhamba imwe yakaderera zvakanyanya, nekuda kwekukanganisa kwemakwikwi kubva kune jenaric. Bhodhi rakagumisa kuti iyo insulin mutengo spike yaifambiswa nekugara yakasvibira - mune iyi kesi, kushandiswa kukuru kweazvino, anodhura akareba-anoita insulins neBig Three.
Dambudziko riri pasi pekutonga kwekugadzirwa neoligopoly rinoramba risati ragadziriswa.
Ichi chinogona kunge chiri chimwe chikonzero nei California iri kusarudza imwe nzira yehasha. California neCanada dzine huwandu hwevanhu vakafanana (39 ne38 miriyoni, zvichiteerana). Kana simba rekutenga reCanada rave kutanga kunetsa kuchengetedza mitengo yakaderera, California haifanire kuita zvirinani.
Kugadzira makambani everuzhinji ezvinodhaka hakusi kufungidzira-mune-denga. Pasi rese, kubva kuSweden neUK kuenda kuIndia neMassachusetts, kune makambani emishonga ari eruzhinji uye ese anogadzira mishonga iyo mafemu akazvimirira anoona isina pundutso yakakwana uye anoita semukwikwidzi weveruzhinji anodzikisira mutengo wemishonga inogadzirwa nevanhu vakazvimiririra. vagadziri. Aya mafemu anogona zvakare kushanda kune imwe nzvimbo muketani yekugovera mishonga, kubva pakugadzira kemikari kana yebiological mapipu kusvika pakugovera nekutengesa.
Nekushanda kunze zvinodiwa pamusika sekuwedzera purofiti uye kutsvaga rendi, mabhizinesi ezvinodhaka everuzhinji akasununguka kukoshesa hutano hweveruzhinji, kufambira mberi kwesainzi, kusimukira kwehupfumi, uye kutsvaga mishonga isinga batsire uye mamwe marapirwo (kusanganisira zvirwere zvisingawanzo), kurwisa kushomeka, kugadzira kuwedzera kwesimba munjodzi, uye kugadzirisa kusagadzikana kwemutengo pane dzimwe nguva.
Mumakore achangopfuura, kukurumidza kwesarudzo yeruzhinji ye insulin kwave kuwedzera.
Muna 2018, Senator Elizabeth Warren akabuda achifarira hurumende yemubatanidzwa kugadzira yayo insulin biosimilar kugadzira nzvimbo. Gore rino, seneta wedunhu reMichigan, Curt VanderWall, wekuRepublican, akaunza chirongwa chekuti hurumende yehurumende igadzire insulin yayo uye kuitengesera kuMichiganders nemutengo, neshuviro inosvika madhora makumi mashanu pabhodhoro. VanderWall vakati vanotenda kuti hurongwa uhu huchabvumira nyika kunzvenga maPBM.
Kujoinha kuedza kweMichigan, muna Chivabvu, Maine akapasa mutemo kugadzira komisheni kuti iongorore kana nyika ingagadzirawo insulin yayo tandem neYunivhesiti yeMaine. Nehudiki hwayo, nyika inogona kunge isina zvekushandisa kana musika wakakura wakakwana, nokudaro hurumende inoti yakavhurika kuongorora kudyidzana nevemasangano akazvimirira kana mamwe matunhu, uye iri kukumbira hurumende yemubatanidzwa kuti itore matanho.
Uye mwedzi wapera, mune yakanyanya kongiri "People's Insulin" chiito chakatorwa, bhajeti renyika yeCalifornia - richangosainwa naGavhuna Gavin Newsom - yakapa madhora zana emamiriyoni ehurumende kuti iite kondirakiti nekugadzira yayo insulin kuburikidza nekambani yeveruzhinji inonzi CalRx uye kutengesa "pedyo nemutengo," inowanikwa kune vese. Iwo mameseji achiri kuda kugadzirwa, asi zvakadaro rinotaridzika Mamiriyoni makumi mashanu emadhora emari ichaenda mukugadzira akachipa anochinjika biosimilar insulins uye imwe madhora makumi mashanu emamiriyoni ekuvaka nzvimbo yeCalifornia-based insulin yekugadzira nzvimbo.
Pamadhora zana emamiriyoni, iyi iri pamucheto wakaderera weiyo yambotaurwa avhareji mutengo wekugadzirwa kwebiosimilar, asi zvichiri mukati meiyo. Saka ndeipi mikana yekubudirira?
"Dzimwe Nyika Dzinogona Kuenda: 'Ah Mirira, Ini Ndinogona Kuita Izvo Zvakare'"
VaPaul Williams, mukuru weCentre for Public Enterprise, tangi rekuAmerica rinosimudzira veruzhinji zvinhu nemasevhisi maererano nezviri kurongwa neCalifornia, vanoti nyika iri kurwa nemamwe mavanga chaiwo.
"Vatatu Vatatu vaenda kumunwe-kugunwe nevanhu vakaita saMerck, nevagadziri vemagetsi emuIndia, vane ruzivo rwakawanda nemhando iyi yechinhu kupfuura Sacramento - uye vakakunda," akaudza. Jacobin. Merck ikambani yechinomwe pakukura kwemishonga pasi rose, uye chimwe chezvigadzirwa zvayo zvikuru, Januvia, ndeimwe yemishonga iri kutengesa chirwere cheshuga pasi rese, kunyangwe isiri insulin.
“Vane mutambo. Kana vakakwanisa kutenga chikara chinovhima seMerck, vanogona kunge vaine chivimbo chekuti vanogona kuita zvimwe chete neCalifornia. "
Asi Williams anotenda kuti pfungwa iyi yakanaka uye kuti California, senyika ine vanhu vakawanda mumubatanidzwa, ine pfuti iri nani kupfuura chero ani zvake. Zvakatonyanya kukosha, vamwe vanogona kukwikwidza vakaita seMerck neIndia vagadziri vejenariki vakadzvanywa makambani anoita purofiti. Nyika inogona kukurira madutu ekurasikirwa nenzira iyo ye-purofiti haigone.
Kana CalRx's insulin gambit ikabudirira, zvinomanikidza vamwe vatengesi kudonhedza mitengo yavo zvachose kuti vakwikwidze.
"Pfungwa yesarudzo yeruzhinji yakawana rap yakaipa kubva kuna Pete Buttigieg paaitaura nezvazvo seimwe nzira yeMedicare for All," anowedzera Williams. "Asi izvo zvaive muchimiro chekuyedza kukunda imwe nzira iri nani iyo inotoshanda mudzimwe nyika dzakawanda."
Saka fungidzira: kambani yehurumende ye insulin inoita semukwikwidzi weveruzhinji achivavarira kusunungura rendi mumisika ye oligopolistic. Inobudirira mukudzikisa zvakanyanya mitengo ye insulin uye kutyora kumashure kwe insulin oligopoly - kuwana kukunda kukuru, kwepamusoro-soro kunoratidza kushanda kwehurumende mushure memakumi emakore ehudhimoni hwekuronga hupfumi uye hutongi hweveruzhinji.
"Dzimwe nyika dzinogona kuenda: 'Ah imbomira, ini ndingazviitawo? Uye kune mamwe madhiragi?" anodaro Williams. "CalRx inogona kushanda sechirongwa chekuratidzira, ichiratidza kugona kwemabhizinesi everuzhinji, ayo anogona kuzotanga kuwedzera kwete kune mamwe madhiragi chete, asiwo mamwe matunhu, kubvisa-njodzi hunyanzvi, kugadzirisa kusagadzikana kwemitengo, kukunda kushomeka kwekutengesa - mune mamwe matunhu. mashoko, achiumba misika pane kungoisiya ichibvarura.”
Chokwadi, mibvunzo mizhinji yasara. Ko CalRx's insulin ichaganhurirwa kumusika weCalifornian, uye saka inongotyaira iyi mitengo yemitengo muGolden State? Iyo Goridhe State ingabatana here nevanofarira veMichigan neMaine kuparadzira mitengo yakaderera ye insulin munyika- (kana kunyangwe pasirese-) pakafara?
Ibasa rei rine California kune dzimwe nyika? Kune vamwe vese pasi rose varwere ve insulin? Kana California yaizotengesa insulin yayo kunze kwemiganhu yayo kuti iwane purofiti yekubatsira chirongwa chisingabatsiri mudunhu, yaizotanga kufarira mitengo yakakwira kumwe kunhu - isina kusiyana neBig Three.
Izvi ndizvo chaizvo zvakaitika neNovo Nordisk. Ndirwo ruoko rwekuita purofiti yehwaro hwakapfuma kwazvo hwekubatsira pasi rose, iyo Novo Nordisk Foundation, inotarisa pakutsvaga kwekurapa. Novo Nordisk iripo kubhengi hwaro, iyo inopa mazana emamiriyoni gore rega rega kumasainzi, varapi, uye akasiyana mapurojekiti ekubatsira vanhu. Uye zvakadaro Novo Nordisk zvakare, semuenzaniso, yanga iri mhosva ye2019 kirasi chiitiko ichiti iyo, pamwe naEli Lilly naSanofi, vakaita "mujaho wezvombo" kuwedzera mitengo ye insulin.
Idzi nyaya dzekupedzisira dzinonyungudika, chero California ichizvipira kuchengetedza isingaite purofiti mukuedza kwayo kwe insulin. Ndiwo musika ndiwo wakanyanya kukonzeresa dambudziko, pane kuti "corporate-ness," saizi, kana huori.
Insulin Socialism?
Chiratidzo chiri pamusoro chenzira yedanho rekugadzirisa basa revashandi vehurumende inogona kurova vamwe vesocialist sevanonyanyisa kana kusanzwisisa zvakakwana mune zvavanoda. Vamwe vangahuramba se“utongi hwezvido zvevanhu,” panzvimbo pehutongi hwegutsaruzhinji.
Kutaura chokwadi, saka chii? Ese mapurojekiti makuru edemocracy socialism anokurudzira kuyemurwa kwakadai muUnited States nekumwewo - Canada neBritain hutano hwehutano, dzimba dzeveruzhinji dzeAustria, iyo panoply yezvirongwa zvemagariro eScandinavia uye muridzi weveruzhinji - akatanga nekuratidzira kudiki, kwechikamu, kana dunhu kwakazotevera. yakaita kuti shanduro dzakazara dzigoneke. Dunhu reSaskatchewan rakaendesa inishuwarenzi yehutano yemunhu mumwe chete, makore isati yagamuchirwa padanho renyika. Iyo UK's National Health Service yakazvimisikidza pamasangano emubatanidzwa wevashandi, asi pamwero wenyika yose. Vanhu vakaona nzira idzi dzekugarisana uye dzekushandira pamwe dzemabhizinesi dzanga dzatoshanda zvakanaka, zvirinani kupfuura vamwe vavo vakazvimiririra, uye zvino vakavimba kuti vaigona kushanda pamwero mukuru.
Uyewo iyi nzira yokuchenjera haisanganisi kudiwa kwekurwisana kwevanhu munzvimbo yebasa, mumigwagwa, uye munharaunda kuti vawane mvumo kubva kune vepamusoro-soro, kana kuti kudiwa kwokutora matanho epamutemo kune masangano. Pane zvakasiyana: vose vanoshanda pamwe chete. Street-level hasha - senge zvinopikisa kunze kwemahofisi eSanofi naEli Lilly evabereki vakafirwa nevana nekuda kwekupihwa insulin, vachibata madota evana vavo sezvavakaita izvi - inoburitsa chido chezvematongerwo enyika chinodiwa kudzika mirau kana kumisa mabhizinesi everuzhinji.
Nhoroondo inoratidzawo kuti matanho anofambira mberi anogona kubva kune zvisingambofungidzirwe. Mumakumi emakore mushure meHondo Yenyika II, yanga isiri maEuropean social democrats chete, asiwo mapato epakati-kurudyi akaunza matanho ehurumende yerubatsiro: bato revashandi, kuburikidza nemasangano evashandi nemapato, rakachinjisa zvakanyanya nzvimbo yezvematongerwo enyika kuruboshwe. VaElite vaitya kuti kana vakasasiya rimwe resimba ravo nehupfumi kuti vagadzirise magariro, vaizoitwa vasina basa.
Isu hatisi panguva iyoyo nhasi. Bato revashandi reUS harina simba, uye dzidziso dzakawanda dzisina hwaro, dzisina humbowo dzeneoliberalism dzichiri kutonga muDemocratic Party. Asi mhepo dziri kushanduka dzezvematongerwo enyika kubva pakaparara zvemari muna 2008 dzakavhura mikana mitsva yezvirongwa izvo zvinopa mukana kune zvechinyakaresocialist zvinoda kuronga hupfumi. Chokwadi, izvi zvinobatsira kutsanangura kuti sei insulin socialism iri kukwidzwa nemaDemocrats ane mwero uye kunyangwe maRepublicans: inozivikanwa zvakanyanya pakati pehasha dzakapararira nekusarongeka kwe insulin.
MaSocialists angave akachenjera kutora mutemo uyu touumba kune zvatinoda - "insulin yevanhu" kwete "California-chete insulin." Izvi zvinoreva kumanikidza maDemocrats seNewsom nemaRepublicans seVanderWall: kana CalRx ikayedzwa nekutengesa-purofiti kunze kweCalifornia kana mhiri kweUnited States, Kuruboshwe kunofanirwa kutsanangura kuti sei kuita izvi kungakanganisa seti yevashandisi ve insulin kune imwe, uye kuronga kushora. .
Kuruboshwe kunofanirwawo kusundidzira kuwedzera misimboti yebhizinesi reveruzhinji kuseri kwekugadzirwa kwenyika kwe insulin kusvika pakugadzirwa kwemamwe mishonga - pamwe nekupindira kwehurumende kwakabatana sekutemerwa kwemitengo, kushandiswa kwekuziva kwekutenga zvinhu kugadzira misika, uye shanduko yezvivakwa zvehungwaru - uyezve kune mamwe matunhu. . Insulin iri kure neiyo chete yakanaka kana sevhisi inotambura kubva kune oligopoly, zvipingaidzo zvekupa, uye antisocial mutengo mhedzisiro. Kubudirira nemakesi aya kwaizotipa mamwe marezinesi ezvemagariro ekusundidzira mamwe-akanyanya mazinga ekupindira, senge nyika uye mutemo wemaindasitiri.
Nekufamba kwenguva, vavariro yeiyi nhanho nzira yakatokura. Mubairo uyu sutu yepro-vashandi mitemo inotungamira kugara zvakanaka kweveruzhinji uye budiriro pamusoro pemusika. kumativi ose pane kungoita seimwe-nguva kugadzirisa kugadzirisa kukanganisa kweimwe kukundikana kwemusika.
Pakupedzisira, chinonakidza nezve chirongwa cheCalifornia cheruzhinji che insulin ndechekuti ndechimwe - asi panguva ino chishuwo - muenzaniso wechimiro chitsva chinotyoka nemakumi mana emakore apfuura e "neoliberal pfungwa" ichitiudza misika inonyatsoziva. Uye CalRx haisi kungoburitsa hasha pahurongwa hwakashata: inhanho yakanyatsofungwa, inovimbika nenyika huru yeAmerica kugadzirisa kusarongeka kwakanyanya kwemamiriro ekunze anodhura zvakanyanya.
Panguva iyo kuodzwa mwoyo kwakawanda, uku ndiko kukura kwakanyanya munzira inoshanda yekubvisa iyo system.
ZNetwork inopihwa mari chete kuburikidza nerupo rwevaverengi vayo.
dhoneta