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Why the 10/90 gap is still 100% fiction
Commercial research has global health benefits

Philip Stevens
Medical Progress Today
November 9, 2006

An erroneous axiom in the world of public health is that markets can never improve the health of the poor. The notion that just a few medicines exist for certain tropical diseases is used as evidence of broad market failures and thus justifies significant government intervention in how new drugs are researched and developed. In reality, the reverse is true: commercial medical research in wealthy markets underwrites global health gains in which the poor are the greatest beneficiaries.

The fallacy that commercial research doesn't benefit the poor was formalized several years ago by the Global Forum for Health Research in a construct known as the "10/90 gap"—meaning 90 per cent of resources devoted to health research are spent on diseases that only afflict the wealthiest 10 percent of the world's population. The 10/90 gap has become a clarion call for those hoping to emasculate private sector health research and move towards the nationalisation of R&D.

For instance, the "10/90 gap" provides the intellectual and political underpinnings of Kenya and Brazil's dirigiste proposal for a framework on essential health research, which was put before the World Health Assembly this May. This has led to the creation of a working group at the WHO which hopes, in the medium–term, to provide a binding framework for research and development into the diseases of poverty. At last week’s annual summit of the Global Forum in Cairo, I saw "10/90 gap" branding emblazoned on all the conference materials and backdrops.

I challenged the foundations of the "10/90 gap" in Medical Progress Today back in 2004. Amongst other things, I pointed out that only a small cluster of tropical diseases have no effective treatment, and that these diseases account for a relatively small proportion of the disease burden in poor countries. I also observed that the biggest killers in such countries—like diarrhoeal diseases, chest infections and childhood diseases–are easily treatable with existing drugs and interventions.

In my analysis, the real problem is not a lack of new medicines, but a failure by governments to ensure that those in need get access to existing medicines. Governments have failed to foster effective healthcare systems by increasing the price of drugs through taxation and by creating institutional and regulatory environments that are inimical to risk–pooling mechanisms such as health insurance. These factors are far more relevant to the health needs of poor countries than an alleged lack of new drugs.

If the 10/90 gap was bogus back in 2004, it is looking even shakier today. Every year, the nature and spread of disease suffered in both rich and poor countries converges. According to the WHO, ailments traditionally associated with the affluent West, such as cardiovascular disease, cancer and diabetes, now account for 45 percent of the global disease burden. Eighty–five percent of these diseases now occur in low and middle income countries. Cardiovascular diseases, for example, are now one of the most significant causes of death in lower income countries.

At the end of 2005, there were around 650 compounds in development for these three diseases alone. This can hardly be described as a 'market failure'. Lower–income countries also benefit from drugs that were originally developed for wealthier markets. Polio, pertussis and diphtheria, for example, were once endemic in wealthier countries, but have been practically eradicated from these areas due to simple vaccines that were developed a few decades ago.

Now, three–quarters of the world's children—including millions in low–income countries—are vaccinated against such diseases, saving at least three million lives a year and preventing long term illness and disability in millions more. Tuberculosis treatments were originally devised to combat the disease in wealthier countries, and many populations in lower–income countries now reap the dividends of this advance in medical science in the form of mass vaccination programmes. HIV/AIDS treatments in the form of antiretroviral drugs (ARVs) were originally developed with wealthy consumers in mind. ARV treatments have now spread to poorer countries which are most affected by the disease, but are unable themselves to bear the cost of R&D for such treatments.

Statins are also an increasingly important tool in the fight against cardiovascular diseases in lower–income countries, with many of these powerful drugs now off–patent and open to generic competition. Again, these treatments originated—and are still being developed—in wealthier countries under the current commercial R&D paradigm.

Seen in this light, the "10/90 gap" is absurd. In fact, the truth is quite the opposite. The vast majority of health R&D is conducted and largely funded by a handful of wealthy countries. According to figures compiled by the Global Forum itself, 90.1 per cent of all such R&D worldwide is conducted by just 10 countries, with the USA accounting for a massive 50 per cent of the total.

From these figures, a back of the envelope calculation reveals that 10 per cent of the world's population is shouldering the R&D costs for the remaining 90 per cent (accounting for the fact that 43 per cent of the total research is done by the public sector in these countries, which also represent the most significant markets for health products). So there is indeed a "10/90 gap"—but it is based on the rich subsidising the poor! But this is hardly going to galvanise political and health activists...

Nevertheless, it is still legitimate to enquire what is being done to develop treatments for diseases which historically have been largely neglected by the research community. Work done by Mary Moran at the London School of Economics has revealed a remarkable level of new activity in this area with the formation of dozens of Public Private Partnerships (PPPs) between public research institutes and the private sector. As a result of these initiatives, there are at least 63 drugs in the pipeline for HIV/AIDS, 30 for malaria and 22 for tuberculosis. In addition there are at least 24 drugs at varying stages of development for neglected diseases such as Trypanosomiasis, Chagas, Leishmaniasis and dengue.

Clearly, things are moving in the right direction. But the continued use of the "10/90 gap" by organisations such as the Global Forum is extremely counterproductive. It fosters a mentality of 'us and them' between public and private sector health researchers which is harmful. This is evidenced by the fact that the private sector shunned the Cairo summit—of some 600 delegates, I counted only three from the private sector.

The various PPPs that are doing such great work for the diseases of poverty could not operate without synergy, cooperation and understanding between the public and private sectors. As such, the private sector should be seen as a partner, not an enemy. Governments should also recognise that the private sector is better placed than the public sector to produce the next generation of drugs that will help both rich and poor alike, and should be cultivated, not censured. Ideological fallacies like the "10/90 gap" undermine this process and have no place in responsible policy debate.

Philip Stevens is the Health Programme Director at the London-based International Policy Network, and is the author of numerous health policy publications, including Free trade for better health (2005), The real determinants of health (2005) and The 10/90 Gap and the diseases of poverty (2004). His writings on health policy have appeared in a wide range of international newspapers. Philip has also held research positions at the Adam Smith Institute and Reform in London, and spent several years as a management consultant. He holds degrees from the London School of Economics and Durham University.

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