Richard Feachem

The diseases that have the biggest impact on global public health receive relatively minuscule amounts of government and corporate funding for research into new therapies. In December, representatives of funding organizations, biotechnology companies and research programs gathered in Washington, D.C.Footnote 1, to try to address a major cause of this disparity: the disconnect between public need and market reality.

Although a few speakers tried to communicate the magnitude of the infectious disease burden on poor countries, Richard Feachem, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, explained, “It's fashionable at these kinds of gatherings to say 'I don't need to tell you how bad it is', but I think we do need to tell each other how bad it is, and we need to keep saying this, because we really haven't got it.” Pointing to the HIV pandemic, Feachem said “it is by far the largest catastrophe in recorded human history. It's already worse than anything else we're aware of, [but] it is not going to peak until 2050 or 2060 if we continue to do as little as we're doing at the moment.”

Other current epidemics are no less apocalyptic. Expressed in disability-adjusted life years (DALYs), a favorite tool of economists that accounts for a disease's effect on an economy, malaria is a problem at least 400 times more significant than global terrorism, and eight-fold worse than war.

Unfortunately, the world's most serious diseases affect the people least able to pay for new treatments. For comparison, one speaker pointed out that the state of Connecticut spends more on healthcare than the 38 countries of sub-Saharan Africa combined. The absence of a profitable market, and the enormous research investment required to produce an effective drug deters most biotechnology and pharmaceutical companies. Peter Young, president and CEO of biotech company AlphaVax, explained that “I'm embarrassed about being this crass, but ... I have an 18-month cash horizon, so I have to say 'show me the money'.”

Participants advocated two main types of solutions for this dilemma, known as 'push' and 'pull' measures. Push measures help companies reduce the costs of drug development, through either direct funding or indirect mechanisms like tax breaks, and have been used successfully to spur drug development for 'orphan' diseases that affect small populations. Elias Zerhouni, director of the NIH, also promised that the NIH would adopt a new policy of 'aggressively' seeking out partnerships with drug companies. He said that the 62 of BIO's 900 member companies that have NIH grants is too low a figure.

Push measures alone, however, cannot offset the enormous costs of drug development without a profitable market. This is where pull measures, such as guarantees to purchase set amounts of any successful treatments, might help. In theory, the guarantee of a market should drive companies to compete in developing drugs for poor countries, but this approach is largely untested.

One pull strategy is the United Nation's Global Fund to Fight AIDS, Tuberculosis and Malaria. The Fund has already awarded grants worth about $600 million over the next two years to finance drug purchases, treatment programs and prevention campaigns. According to Feachem, the organization's expenditures will have to reach about $10 billion per year by 2007 to be effective against the three diseases—a staggering sum relative to other aid programs, but less than a tenth of the anticipated costs of a US-financed war against Iraq.

The comparison of public health costs with war budgets is likely to become more common, as several speakers noted, because the US Central Intelligence Agency and Department of Defense have begun expressing concern about the destabilizing effects diseases like AIDS are having on many countries. “I feel that in the 21st century, not handling this issue may become a major security risk for all of mankind,” said Zerhouni, a sentiment recently echoed by US Secretary of State Colin Powell.

Elias Zerhouni

Concern about infectious diseases also extends higher in the administration, especially with respect to bioterrorism. Anthony Fauci, director of the National Institute for Allergy and Infectious Disease, argued that “it might be the biodefense products that trigger a process that can be universally used with other products.” Specifically, Fauci has recently been working with NIH's supervising agency, the Department of Health and Human Services (HHS), to establish “some sort of program that is separate from the NIH budget that would be responsible for the chain from development to testing to ultimate purchase” of some new therapies.

The new HHS system might include pull measures, like funds to purchase vaccines once they are produced, as well as push measures to help companies pursue research more aggressively. “I think you're going to see some things that will please you over the next year or so,” Fauci told an enthusiastic audience.