Monday, May 7, 2012

To boost global health research, cut US federal global health R&D

According to a new report by a Washington, DC advocacy group,  "the US Government each year contributes around 45% of all investment in global health R&D and 70% of all government investment worldwide." 

Also from the same report: “The US government’s investment in early basic (global health) research is so great that it now provides nearly two-thirds (62%) of global funding in this area,”

The report put out by the Global Health Technologies Corporation (GHTC) seems to define "global health" as communicable disease (and not, for example cancer or diabetes), so I'm a bit suspicious that the math behind the conclusions may be cherry-picked, but just accepting the figures my first reaction is that the high level of government support is BAD news for global health, and that the best thing that could happen would be for the US government to step back. Here's why I think that:

-Global health R&D is intended to benefit poor 3rd world patient populations, yet the bulk of the global health research is targeted to very a commercial market. According to the report, HIV R&D constitutes 57% of the global health R&D budget, as monitored by GHTC, so parsing the numbers would lead to the conclusion that there is already significant private sector research in HIV, just as there are very significant therapies having been discovered and commercialized by the private sector.  Indeed, while the largest patient population for HIV therapies may be among very poor in Africa, this seems to me to be as much a distribution/manufacturing problem, and not an R&D challenge so much. If private sector HIV research were leading the way, the global health resources could be devoted to other research areas (cancer, etc.) and non-R&D assets like USAID could assume a bigger role in HIV treatment, especially in delivering HIV therapies.

-I don't like the idea that global health research strategy is largely driven by one large customer (the US Government.) Not to knock the people and funding process of the NIH/DoD/etc - and I know their research strategy isn't monolithic - but I would much, much rather see global health research strategy driven by a plurality of voices. Science doesn't progress as fast when one R&D catechism is dominant. Historically, much of our progress in life science is due to researchers with quirky or contrarian strategies swimming against the majority of researchers. No government body is very flexible in this regard.

(The best example I can think of here is Dr. Judah Folkman's pursuit of anti-angiogenesis. Once cast into the wilderness of cancer research by the cancer research establishment, Folkman's strategy is now an integral part of cancer therapy, as embodied by drugs such as Sutent and Avastin.)

-Likewise, unfortunately US global health policy is in part driven by politics, at least as significantly as the best scientific rationale or the aim of the most significant scientific impact. I'd rather more wise people steer global health R&D than the jokers in Congress. 

-I favor global health R&D being driven by the private sector, with the government as a ultimate backstop, with the goal that global health R&D could be more market-oriented, but in an untraditional way. Market-oriented would traditionally be defined as financial demand tied to the patients' (or other payers) ability to pay. In the case of global health R&D, I think market-oriented would reflect (non-financial) patient demand, to include the amount of charity resources being devoted to a particular disease. I think by weighting R&D by this metric, we're more likely (for example) to place greater weight of clean water than TB, as the number of people with poor health due to a lack of access to clean water is many times greater than those at risk for TB. (The fact that clean water may be less of a biotech R&D issue and more of a civil engineering challenge underscores the point that the US government tends to mis-allocate R&D assets.)

-Finally, I'm annoyed by the idea that much of the first world is free-riding on America. The US accounts for ~27% of World GDP, and with US government being approximately 1/3rd of US GDP, this means that roughly 9% of world GDP funds 45% of global health R&D. I'm pointing the finger here at other first world powers to pull their weight. Unfortunately, to react to this point by cutting US federal global health R&D to equalize efforts puts others in jeopardy, but I highly doubt that other governments will spontaneously decide to pull their own weight in this area. 

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