FWIW, you have the exact same system with college textbooks: the International Edition we get in Europe is often 30-50% cheaper than the US Edition, and has big letters saying &quot;Not for sale in the US or Canada&quot;. Then you also have a further Low Price Edition, saying &quot;Not for sale outside India, Pakistan, ...&quot; which I&#x27;ve seen at 1&#x2F;10th of the US price, though usually printed on lower quality paper and lagging an edition behind.<p>This suggests that pharma is not a special case. And you can&#x27;t point to any huge R&amp;D costs for textbooks that are subsidized by the US.