Is the proposed cure for the world's health problems worse than the disease?
IPN Opinion article
Mexico City - One of the central themes at the global forum on health research is that while pharmaceutical companies pour resources into finding cures for baldness and erectile dysfunction, millions of people in low-income countries are dying of tropical diseases for which there is no cure. Unfortunately, the problem seems to have been misdiagnosed and, as is so often the case with inappropriate diagnoses, the proposed cure may be worse than the disease.
It is true that millions of people in poor countries are dying of tropical diseases and it is true that the pharmaceutical companies are investing billions of dollars into ëlifestyle' diseases. However, the assertion that poor people are dying because rich people demand pills for erectile dysfunction, while appealing, is simply untrue.
The conference here is centred on the idea that only ten per cent of global health research is devoted to conditions that account for 90 per cent of the global disease burden - the so-called ë10/90 gap'. In spite of its rhetorical appeal, the 10/90 gap is a myth. It is manifestly not true to claim that the diseases that constitute the biggest problems in the poorest countries are ignored in terms of research and investment.
In order to lend substance to the 10/90 gap, activists cite statistics showing a lack of R&D activity surrounding a clutch of tropical diseases suffered exclusively by the world's poorest people. They will point out, for example, that one per cent of all the new drugs approved between 1975 and 1999 were for infectious tropical diseases. But they fail to mention that such diseases only make up a tiny fraction of the disease burdens of low-income countries.
The relatively low level of current research activity on these diseases is a reflection of the fact that effective treatments have already been invented for most of them. According to the WHO, only three diseases might truly be classified as ëneglected': African Trypanosomiasis, Chagas disease and leishmaniasis. Even for these, a number of potential treatments are currently being investigated by pharmaceutical companies.
Sadly, the whole 10/90 debate actually serves to obfuscate the real issue, which is that most disease and death in poor countries are the result of poor nutrition, indoor air pollution and lack of access to proper sanitation, health and education. Significantly more people die from diarrhoea each day than from all the so-called ëneglected' diseases combined. The same is true for smoke-induced respiratory diseases and malnutrition.
The tragedy is that nearly all of the death and misery associated with diseases of poverty could be avoided if the world's poorest people could actually gain access to the myriad of cheap medicines and preventative techniques that already exist. However, all too often governments deliberately hinder their peoples' access to essential medicines by pursuing counterproductive and obstructive policies.
Millions of poor people are priced out of treatment by their own governments which impose a range of punitive taxes and tariffs on medicines. 65 per cent of the population of India has no access to essential medicines in part because the Indian government raises the cost of imported medicines by 55 per cent through a range of taxes and import tariffs. Governments also all too often skew their spending priorities in favour of defence over health. The government of Pakistan, for instance, spends 4.7 per cent of its GDP on defence, but a mere 1 per cent on healthcare.
More fundamentally, much of the disease burden of low-income countries is caused by their governments' failure to create the conditions in which wealth can be created. Greater prosperity creates a virtuous circle, which allows people to improve their nutrition and sanitation, as well as having better access to education and healthcare.
The governments of poor countries often hinder the creation of wealth, imposing obstacles in the way of owning and transferring property, imposing unnecessary regulatory barriers on entrepreneurs and businesses, and restricting trade through extortionate tariffs. It is these and other political failures that have left poor populations without the necessary resources to access the medicines that could so easily transform their quality of life.
The WHO has observed that a healthier population is better able to engage in economic activities and thereby generate extra income, creating a virtuous circle. This is no doubt true. However, it does not necessarily follow that improving the health of the population will kick-start this process. If people are prevented from engaging in economic activities, then no amount of improvement in population health will enable people to escape from the lowest rung.
What of the suggestion that the public sector can successfully take on the burdens of pharmaceutical R&D? This is the premise underlying a proposal to create a ëGlobal R&D Treaty'. The historic experience suggests this proposal is insanely optimistic at best and dangerous at worst. The public sector has proven to be extremely ineffective at identifying and developing treatments for diseases.
Lack of accountability is a major problem. Public sector researchers are rarely ëresults oriented' in the same way that the private sector is. As a result, there is less incentive to ensure that funds are appropriately used. In the late 1980s, a public-sector project to develop a vaccine for malaria led to millions of dollars disappearing into researchers bank accounts. By contrast, private sector pharmaceutical companies have been forced by competitive pressures to develop technical skills and commercial acumen that enable them to make decisions about which molecules are worth developing into drugs.
To entrust the public sector with the vital task of developing medicines for the new health threats that loom on the horizon, such as avian flu and drug-resistant strains of tuberculosis, smacks of woolly political utopianism. Furthermore, it is vital to ensure that we have a continuing stream of new drugs to combat diseases that are traditionally associated with the rich world, such as cancer and heart disease. These are becoming increasingly significant killers in lower-income countries. The R&D-based pharmaceutical companies have dozens of compounds in the pipeline to address these disorders, which stand to benefit both rich and poor people in the future.
Well-meaning attempts to reform the system through which R&D is conducted may have the unintended consequence of undermining the incentive system which has produced so many successful drugs for the problems of rich and poor countries alike. If heavy taxation and regulation are imposed on these companies, as is advocated in the proposed Global R&D Treaty, companies will have far less incentive to invest in the risky and costly business of researching and developing drugs.
The current system of R&D has been immensely successful in anticipating demand and shouldering the considerable cost of turning scientific ideas into drugs that are both safe and effective. We should be seeking to strengthen the system instead of seeking to bury it, for the sake of the future health of both poor and rich alike. Meanwhile, if governments care about improving the health of the poor they should remove the barriers they put in the way of economic development and access to medicines.
Mr Stevens is Director of Health Projects at International Policy Network and the author of 'The Diseases of Poverty and the 10/90 Gap', published this week by IPN.