Which is more pressing — providing cheap drugs for neglected diseases or the infrastructure to deliver them?

It depends on the disease and the society in question, but we should not regard them as either/or. Improvements in drug supply will drive the expansion of health services, but without new medicines the efficacy of health services is limited. Médecins Sans Frontières has an extraordinarily good medical delivery system, but had to set up its own initiative to collaborate on affordable cures for sleeping sickness. In Cape Town in 2002 the Treatment Action Campaign told me that their patients probably adhere to the antiretroviral regime as well as those in the United States. So the main issue is drug availability.

The industry does not and cannot produce medicines purely for neglected diseases, because there is no profit to be had, but what it can do is make medicines that have already been developed for rich markets available at production cost to poor markets.

Have other industries been targeted in the way pharma has over issues in the developing world — essentially being asked to forego profits and ROI?

Indeed they have. Fairtrade coffee has been so successful in taking market share that Nescafe and Kraft are setting up their own competing 'fair' brands. Nestlé has also been strongly attacked for years over attempting to stop breast feeding in developing countries, and Monsanto has been targeted for maintaining seed prices by preventing farmers from saving seed. Until recently pharma had it easier than most, perhaps because it has exploited the mystery surrounding drug discovery to create a highly profitable but fundamentally inefficient industry. Around one-third of pharma's revenue is profit and another third goes into marketing — twice as much as is invested in R&D. This allows the industry to hit every UK physician with £20,000 of advertising per year, and in the US advertise directly to the consumer as well. Pharma also spends huge sums on lobbying the US and EU governments to craft bilateral agreements and free-trade areas that undercut the intellectual property rights of poorer countries. The industry does not and cannot produce medicines purely for neglected diseases, because there is no profit to be had, but what it can do is make medicines that have already been developed for rich markets available at production cost to poor markets. This is not a call to forgo profits, because there are no high-price sales there anyway.

To produce new drugs for the truly neglected diseases we need a different system that doesn't depend on return on capital. Pharma has a lot of scientific talent locked up in its labs, and partnership schemes can allow them and their currently unwanted products to be used for the benefit of humanity.

How can we stop cheap drugs being re-imported into the developed world?

With difficulty, but I never understand why this objection is raised, given that the world is full of tariff barriers that are more or less effectively enforced by customs officials. The real issue is counterfeiting. Nobody wants unregistered and untested counterfeit drugs of unknown quality floating around the world. It is far better to agree to discounted exports and/or generic licensing, under supervision of the World Health Organization and conditions of transparent distribution. This will be much easier if we move away from market-driven research, in which drug prices are set artificially high in the first place.

What model should pharma adopt to enable non-market-driven drug discovery?

In addition to some of the approaches already discussed, a more political approach is to provide new incentives: government money could be provided for work on an 'orphan disease'. For example, we heard recently that the UK government has guaranteed GlaxoSmithKline payment for a malaria vaccine of unproven efficacy. However, the discipline of the market place is lost, and in light of GSK recently withholding information regarding paroxetine, some strong umpiring is clearly necessary.

More radical suggestions include the treaty proposed by Hubbard and Love, in which all nations agree to spend ∼0.1% of their GDP on R&D for medicines. All nations spend about this much anyway, because about 10% of the purchase price of drugs goes back to R&D, and countries, rich and poor, spend about 1% of GDP on medicines. The value of the contributions would be weighted to reflect the extent that the research is made public and applied to the most important goals, and R&D would be supported by a mixture of direct funding and rewards to successful teams. Production of drugs would be carried out by a separate competitive market.

In order to move forward with these initiatives we need more input from publicly funded labs in early parts of the drug pipeline and less regard being paid to intellectual property of basic discovery. The World Intellectual Property Organization needs to facilitate open collaborative agreements, rather than simply enforcing existing patent law as the US Patent and Trademark Office would have it do.

So what is the role of pharma in this? To desist from the lobbying that obstructs change, and to re-invent itself: R&D decoupled from production, working in partnership and helping to deliver real global health care. The huge sales forces will have to go, as will exorbitant returns on capital. It will be painful and cannot happen overnight, but surely it's better to plan for a soft landing than to merge and merge until the final crash.