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FORUM Balancing Drug Markets Toward Leveling World Health Renee Hsia Photo by Jeff Cleary Research. Funding. It is almost as if one cannot talk about the former without mentioning the latter. In some cases, needs create funding but, unfortunately, this is not always true. Poor nations face a disadvantage in turning needs into research, leaving a gap in the development of the drugs and vaccines against diseases that disproportionately affect the world's poor. Neglected diseases include leishmaniasis, trypanosomiasis (sleeping sickness), and Chagas disease, in addition to the more widely known HIV/AIDS, malaria, and tuberculosis. A study done by the independent Drugs for Neglected Diseases Working Group and the Harvard School of Public Health in 2001 reported that out of the 11 top pharmaceutical companies in the world, seven said their spending for research in malaria, tuberculosis, trypanosomiasis, Chagas disease, and leishmaniasis made up less than 1 percent of their R&D budgets. What are the results of this pattern of investment? In the years between 1975 and 1997, only 13 new drugs out of 1,223 licensed worldwide were for tropical diseases. Public-Private Collaborations Much effort has gone into finding practical solutions for making global need more translatable into actual availability, particularly in the past decade. The public sector in the developing world has tried intervening through several of its available weapons: public provision, regulation, and taxes and subsidies. Western governments also have tried tinkering with regulation and tax incentives to stimulate the private sector. Regulatory mechanisms have included orphan drug legislation and fast-tracking research through clinical trials if it meets certain criteria. The results have been mixed, however, and in response to the perceived market failures and inadequate government mechanisms, numerous public-private initiatives have sprung up as new vehicles for drug and vaccine development. These include the Drugs for Neglected Diseases Working Group, the International AIDS Vaccine Initiative, the Global Alliance for Vaccines and Immunization, the Global Alliance for TB Drug Development, and the Global Forum for Health Research, to name a few. An exciting addition to this public-private dialogue is based on the idea of creating incentives to draw the private sector into neglected arenas. One way to attract for-profit companies is to ensure that a market will exist if the product is developed. Leaders like Michael Kremer and Rachel Glennerster from Harvard's Center for International Development have proposed the idea of "purchase precommitments," in which an international body or group of countries band together and guarantees their purchase of a drug or vaccine if it is developed. The purchase precommitment must be large enough to be a real financial incentive, yet the amount does not have to cover the cost of consumer advertising since the buyers are already lined up. Mechanisms like this would guide the global community away from finger-pointing at Big Pharma and, instead, toward constructive conversation about how to structure the market to benefit all stakeholders. It goes without saying that along with these initiatives to stimulate more research, huge advances still need to be made in the area of health care infrastructure and funding mechanisms. Hepatitis B, for example, remains a prominent problem despite the existence of a vaccine, since countries find themselves unable to afford the purchase and delivery of the three-dose therapy. Worst-Case Scenario Though solutions are not easy and numerous mistakes have been made in reducing the inequity between the haves and have-nots, the alternative--to do nothing--is even more unacceptable. The infamous case of eflornithine, a drug that can cure trypanosomiasis, is a stark reminder of what can happen when markets fail and the world stands idly by. Sleeping sickness is a disease that in 1999 was responsible for more than 60,000 deaths. But due to a lack of profitability, production of this drug ceased in 1995. Until, that is, five years later, when someone discovered that one of its side effects was to stop the growth of facial hair in women. Rather than continuing a cycle in which the destiny of the world's poorest depends on the caprices of the developed world, we can only hope that more thoughtful and innovative approaches can begin leveling the playing field of health access and health status. --Renee Hsia, a fourth-year medical student at HMS