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Why the 10/90 Gap is 100% Fiction
Pharmaceutical companies aren’t to blame for the disease burden in poor nations.

Philip Stevens
December 2, 2004

One of the central themes of November’s Global Forum on Health Research meeting in Mexico City was that while pharmaceutical companies are pouring billions of dollars 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. This is called the “10/90 gap”, i.e. only 10% of the world’s pharmaceutical research goes towards diseases that account for 90% of the global disease burden.

In order to counter this imbalance, the Global Forum called for a complete redesign of global pharmaceutical R&D to ensure that more resources are directed towards so-called neglected diseases – possibly including an “essential research obligation” that would require companies to invest a percentage of profits into research for neglected diseases, or even a “Global R&D” treaty that would shift most pharmaceutical research into the public sector.

Unfortunately, the Global Forum has misdiagnosed both the problem and the solution and, as is so often the case with misdiagnoses, the patient will suffer more from a bad cure than the underlying disease.

It is true that millions of people in poor countries are dying of tropical diseases and it is true that pharmaceutical companies are investing billions of dollars into research for ‘lifestyle’ diseases. However, the assertion that poor people are dying because rich people demand pills for erectile dysfunction, while appealing, is simply untrue. The 10/90 gap is a myth that obscures the real problems plaguing the world’s poorest countries.

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 burden in low-income countries, accounting for only 0.5 per cent of all deaths.

Indeed, 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 ‘neglected’: African Trypanosomiasis, Chagas disease and leishmaniasis. Even for these diseases, a number of potential treatments are currently being investigated by pharmaceutical companies.

The truth is that most disease and death in poor countries is the result of poor nutrition, indoor air pollution and lack of access to proper sanitation (primarily clean drinking water), health care and education. According to the WTO an average 5,482 people die from diarrhoeal related causes each day, whilst “neglected” disease kill only 378. Smoke-induced respiratory diseases claim a far bigger death toll than “neglected” diseases, and are the biggest killer of children under five in the world. This is a question of economic development and infrastructure – not pharmaceutical R&D.

The tragedy is that nearly all of the death and misery associated with the real diseases of poverty could be avoided if the world’s poorest actually gained access to the myriad of cheap medicines and preventative treatments that already exist. This isn’t happening because, all too often, governments in poor nations deliberately hinder their peoples’ access to essential medicines by pursuing counterproductive tax and tariff policies on imported drugs. For instance, 65 percent 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.

Punitive taxes and tariffs are only the tip of the bad-government iceberg. Governments in poor nations often hinder the creation of wealth, imposing significant obstacles in the way of owning and transferring property, imposing unnecessary regulatory barriers on entrepreneurs and businesses, and restricting trade and foreign investment. By and large, it is these gross political failures that have left poor nations without the necessary resources to access the medicines that could so easily transform their quality of life.

What about the call for a global R&D treaty that would shift pharmaceutical research into the hands of government researchers? This is a red herring designed to shift power from the private sector towards unaccountable bureaucrats. Historic experience suggests that this proposal is both insanely optimistic and dangerous. The public sector has proven to be extremely ineffective at identifying and developing treatments for diseases, and shifting more resources into this sector would cripple the pace of global drug development.

Lack of accountability is a major problem. Public sector researchers are rarely ‘results 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.[1] By contrast, private sector pharmaceutical companies are forced by competitive pressures to develop technical skills and commercial acumen that enable them to make better 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 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, and the R&D-based pharmaceutical industry has proven itself highly adept at developing compounds to treat these disorders, with dozens of new drugs in the pipeline that stand to benefit both rich and poor nations alike.

If heavy taxation and regulation are imposed on pharmaceutical companies, as is advocated by the Global Forum, companies will have far less financial incentive to invest in drug development, and the world will have fewer new medicines to rely on in the future.

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 current R&D system instead of seeking to dismantle it as a result of misguided ideology.

The unpalatable truth (at least for some) is that poor nations face many severe public health burdens, but those burdens are not generated or sustained by callous pharma companies.

If activists are serious about improving the health of poor nations they should demand that those nations remove the barriers they put in the way of economic development and access to medicines.


  1. Glennerster, R & Kremer, N: “A better way to spur medical research and development”, Regulation, 23(2), pps.34-39 (2000).

Mr. Stevens is Director of Health Projects at the International Policy Network ( and the author of “The Diseases of Poverty and the 10/90 Gap”, from which this article is adapted.

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