The 90/10 divide

If you asked someone starting medical school why they were studying medicine, they would probably say they wanted to help the people in most need. But if you asked final year students the same questions, you would get a different answer.

Ninety per cent of the world is at risk from infectious diseases, but only 10% of the world's research and pharmaceutical resources are spent on them. Drug development for diseases that affect poor people has come to a virtual standstill. Nathan Ford explains how Médecins Sans Frontières is trying to redress the balance with its "Access to Medicines" campaign.

Doctors confronting infectious disease in the less developed world are faced with impossible choices. Effective medicines exist to treat AIDS, but because patients in Africa cannot afford them doctors are left with little option but to tell them to go home and save up for their funeral.1

Patients with malaria are prescribed drugs that do not work because, although in some regions resistance to traditional medicines is over 90%,2 effective treatments are not available. The drug to treat sleeping sickness, melarsoprol, is an arsenic based medicine that kills one in 20 patients and doesn't work for one in three because of parasite resistance: the drug may kill the patient, but without treatment the patient will die anyway.3

Infectious diseases kill 14 million people each year, mostly in the less developed world, but for many of these diseases, drugs are too expensive, ineffective, or non-existent. This is because medicines are big business: the world relies almost exclusively on the increasingly consolidated and highly competitive multinational drug industry to generate new medicines. The private sector typically develops drugs for relatively healthy and wealthy markets, not the suffering majority. The result is that a large part of the world's population is ignored.4

The development of drugs is so skewed towards the needs of rich countries that only 1% of new treatments — just 16 drugs — developed over the past 25 years were for diseases such as malaria, sleeping sickness, and tuberculosis, found mainly in the developing world. Yet these diseases account for over 10% of the global burden of disease.5

For the past three years Médecins Sans Frontières (MSF) has been campaigning to increase access to medicines, pushing both to make existing drugs more affordable and to increase research and development of drugs for diseases that currently are difficult to treat or for which no treatment is available.6 As part of this campaign, MSF has been touring the United Kingdom and Ireland with a mobile exhibition aimed at raising public awareness, to get these issues higher up the political agenda.

The United Kingdom, with a strong tradition in tropical medicine research and home to one of the largest pharmaceutical companies in the world, is in a good position to do more to address the crisis in access to medicines. Medicines for neglected diseases must be considered public goods, not simply consumer products, and governments must take greater responsibility, both by investing more resources themselves and forcing the private sector to do more.

Anup Shah, a medical student who graduates this month from Nottingham medical school, spent several days working at the exhibition in Cardiff. Like many medical students who have witnessed poverty and disease in developing countries on their electives he says: "I've been to developing countries and seen the terrible hardships of people living in extreme poverty, and I strongly believe that the West should do more to help."

Many medical students agree with Shah that the medical community has a duty to advocate for greater access to healthcare for all. But even among students these issues can often be forgotten. As medical students progress through their studies they understandably begin to start to think about their own careers, want to start a family, buy a car, and so on. The broader issues can be easily forgotten.

If you asked someone starting medical school why they were studying medicine, they would probably say they wanted to help the people in most need. But if you asked final year students the same questions, you would get a different answer.

Almost everyone in medical school realises the inequalities in health care. But if these issues are not in your face you do not think about them. The issue of neglected diseases is a striking example of the huge unmet medical needs in the world today.

I think that medical students should pay more attention to these issues, not least because they are a strong reminder of the need to relieve suffering that compels people to join the medical profession in the first place. Doctors from developed countries who are fortunate enough to work in a less developed country see how much medical skills are needed and appreciated there. Such experiences are a vital step in advocating for change.

What can be done to reduce the millions of deaths every year from treatable infectious diseases? High prices can be accommodated if countries are allowed to tackle the market monopolies of pharmaceutical companies and purchase drugs at the most affordable price. Companies are offering heavily discounted prices for their AIDS drugs in Africa, but these drugs are available from countries like India, Brazil and Thailand at up to a 10th of the cost.

New approaches for drug research and development should not be driven by return on investment, but by need. Research and development capacity that is not for profit should also be promoted in the public sector. The pharmaceutical companies, which are among the most profitable industries in the world (thanks to tax breaks), public funded research, and government granted market monopolies, should also do more.7

Without serious political commitment and a clear realisation that there is a public duty towards health issues at a global level, advances in science and medicine will contribute nothing to alleviating the suffering of the millions who die of neglected diseases in the developing world.

We need to understand why billions live on the margins of destitution.8 Modern communication, transport, and the emergence and resurgence of infectious diseases have shrunk distances and differences, creating global risks. There is a moral obligation to be seriously committed to interrupting the cycle of poverty and disease that affects the lives of billions.

To find out more about MSF's work, and the Access to Medicines Campaign, visit


1. Von Schoen Angerer T, Wilson D, Ford N, Kasper T. Access and activism: the ethics of providing antiretroviral therapy in developing countries. AIDS 2001;15 (suppl 4):81-90.
2. Gastellu M, Matthys F, Galinski M, White N, Nosten F. Malaria epidemic in Burundi. Lancet 2001;357:31.
3. Legros D, Ollivier G, Gastellu-Etcegorry M, Paquet C, Burri C, Jannin J, et al. Treatment of human African trypanosomiasis—present situation and needs for research and development. Lancet Infect Dis 2002:2:437-40.
4. MacDonald R, Yamey G. The cost to global health of drug company profits. West J Med 2001;174:302-3.
5. Trouiller P, Olliaro P, Torreele E, Orbinski J, Laing R, Ford N. Drug development for neglected diseases: a deficient market and a public-health policy failure. Lancet 2002;359:2188-94.
6. Pécoul B, Chirac P, Trouiller P, Pinel J. Access to essential drugs in poor countries: a lost battle? JAMA 1999;281:361-7.
7. Angell M. The pharmaceutical industry—to whom is it accountable? New Engl J Med 2000;342:25.
8. Rowson M. The why, where, and how of global health teaching. studentBMJ 2002;10:217-9.