Friday, May 08, 2009

Drugs for neglected diseases: an immodest proposal

People working in bioethics have sometimes been criticized (often by social scientists) for not being radical or critical enough. Instead of speaking truth to power, we have been regarded as purveyors of watered-down or sanitized versions of the truth, hoping that by being 'pragmatic' or 'realistic', the powers that be will actually listen to the arguments and take appropriate actions. The powers in question can be powerful research institutions, international health agencies, pharmaceutical companies, medical insurance companies or Ministries of Health. The problem: the more palatable bioethics arguments are to these powers, the more likely they are to listen, but any changes based on those arguments will therefore be small, incremental, piecemeal. On the other hand, the more adversarial the arguments, the less likely they are to listen at all. And, of course, bioethics institutions are very often closely aligned with some of these very same powers: that is where bioethics acquires much of the authority it has, not to mention much of its funding.
So in this intellectual climate, it is refreshing to read an article laying out a policy that attempts to seriously rock the boat. In the current Journal of Medical Ethics, an article entitled 'Ethical issues in funding research and development of drugs for neglected tropical diseases' (free access) has an argument which basically runs as follows. Research and development on neglected diseases, particularly those affecting developing countries, has been very limited in the last decades, despite these diseases being responsible for vast numbers in mortality and morbidity. Between 1975 and 1999, only 16 new drugs for these diseases were produced out of the 1393 chemical entities developed during that period. One explanation for this situation is the current drug patenting system. Pharmaceutical companies are primarily driven by profit motives, and the patent system gives companies years of market exclusivity for their products. Market exclusivity allows companies to charge whatever prices the market can bear. The most profitable drugs are those which don't demand large research investments, provide some small health improvement for a large population, and respond to health conditions in industrialized countries where many people can and are willing to pay the price for the drug. For these reasons, drugs for neglected diseases affecting the world's poor is simply not interesting from a profit-seeking pharmaceutical company perspective.
The alternative? Scrapping the patent system enjoyed by pharmaceutical companies altogether. Reward the development of new pharmaceuticals from public funds based on the actual impact that they will have in terms of global morbidity and mortality. This would recast the focus from profit margins of private companies (and economic interests of more affluent nations) to global health, a seismic shift particularly important for resource-poor settings with the greatest need for improvement in health and well-being.
Will pharmaceutical companies and national governments buy into this? Not likely. The historical trend is toward short-term self-interest, not long-term public goods. There are very deeply entrenched vested interests who would be strongly opposed to this idea. The public funds probably would not be anywhere equivalent to the kinds of money pharmaceutical companies are making right now. But at the very least, the immodest proposal throws a spotlight on the ethically dismal regime of global drug research and production that we current have.

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