Your health choked by the invisible hand of the market

Sometimes the invisible hand of the markets is all too apparent as it clutches us by the neck and strangles us slowly and painfully. If you are a typical adult American, you are likely to have at least one prescription for a drug indefinitely, either until you die or another drug is developed to replace it.

In the world of libertarian fantasy, pharmaceutical companies would compete to develop drugs we need to cure diseases that plague us. Hoping to sell us their products, they would race to develop effective and inexpensive drugs that consumers would rush to purchase. Unfortunately, those profits would be short-lived. People would buy the drugs, get well, and go about their business drug-free and non-contagious. Companies can make some money that way for sure, but it is much more lucrative to develop drugs that do not cure anyone but simply maintain their health.

This is why we have so many drugs for cholesterol, blood pressure, acid reflux, and other chronic conditions with fewer drugs aimed at eliminating disease, and even fewer aimed at curing (or even treating) diseases that affect those too poor to pay for expensive remedies. The fact that there is any treatment, even in early experimental drug trials, for Ebola is thanks to government funding of research. Left to markets alone, the diseases that kill the most people in the world would be completely ignored by drug companies.

Some diseases, such as Type II Diabetes, affect poor people, but drug companies spend quite a bit of time developing treatments for them. This, of course, is because enough people receive insurance payments from private insurance or Medicare and Medicaid to make treating them worthwhile. Almost 27 percent of Medicare beneficiaries 65 or older have diabetes, accounting for 32 percent of Medicare spending.  in 2002, Medicaid expenditures for people 20 and over with diabetes were estimated at more than $18 billion.

Of course, diabetes also affects people who are relatively affluent by global standards. In fact, it is considered a disease of babymotherdeathoverconsumption notwithstanding the fact that many who suffer from diabetes in the US are less affluent. Thus, it is extremely profitable for companies to develop products and services for diabetics in the US where their profits are underwritten by taxpayers. Diseases that primarily affect impoverished people in poor countries get much less attention.

It would seem likely that donations from individuals could fund research and development into alleviating disease. Indeed, the ALS ice bucket challenge raised more than $100 million as of this writing for research and treatment of ALS. But this again, leaves the allocation of resources to the mercy of marketing campaigns. ALS is a cruel disease, and it will only be a blessing if a cure can be found, but diseases that affect primarily impoverished individuals (e.g., malaria, antimicrobial resistance, trachoma) in the world are still waiting for a viral marketing campaign to draw attention to the millions that die from them. Market-based approaches drive money to those with the most influence.

In order to reduce the burden of diseases that affect the most people, we must provide research funds that are distributed where they will be most effective, rather than where the market funnels them. We need research centers funded by money offered with no conditions with the charge only to reduce mortality and relieve suffering. Such centers could be funded by government money or by individual contributions, but funding must come with no strings attached other than a demand for transparency from researchers as to how the money is used and what diseases are being treated. Some have offered solutions that would rely on industry to conduct research and develop products to alleviate suffering, but industry cannot be trusted with this task. Industry will always develop products to maximize profits, not minimize suffering.

The so-called “rugged individualists” in our society would argue that each person should have the healthcare he or she can afford, as income is a reliable measure of a person’s worth. Unfortunately, disease doesn’t attack people on the basis of merit. Honest and hard-working individuals can and do fall ill or become injured. Some are surprised by their turn of fortune. It is easier for a wealthy person to become poor than it is for a poor person to become wealthy, and disease and injury are great conveyors to the lower classes. Some, of course, are rich enough to be indifferent to the cost of healthcare or even long-term care. Even without working at all, these individuals will be housed, fed and treated.

People who work for their income, though, even in highly paid professions, are vulnerable to losing everything to healthcare costs. The “excellent” health insurance many people rely on is tied to employment and employment is tied to health. The unlucky ones who become ill lose both in a heartbeat. Bad luck isn’t a matter of bad choices or immorality; it is only a matter of chance. Libertarians argue, basically, that people should be responsible for the choices they’ve made in life, but libertarians also feel the government should protect people from events and circumstances out of their control. Thus, libertarians support the use of government funds to provide courts, police, and standing armies to protect the security of citizens.

The risk of disease and injury threatens us all. The question is whether we, as a society, should take responsibility for protecting all our citizens from this threat. If we don’t do this through government action, we must do it through collective action. Single-payer healthcare, such as all other developed nations have, is the most obvious solution to making citizens secure. Other solutions exist, and can be considered, but no one can prepare for catastrophe alone—collaboration is required.

We must provide funding for both medical research and healthcare. I am not asking you to provide healthcare for someone else. I am asking you to share the burden of providing healthcare for yourself. Sure, there is the chance you will never need it, but your chances are no better than anyone else’s. If we are not all secure, we are all insecure, we are at risk of being choked by the invisible hand. If we are insecure, we are not free.






Ebola and the ethics of international drug testing

Ebola has been around for nearly 40 years now, and until recently the public was unaware of any available treatments or treatments in development for the disease. In fact, there is no market incentive for pharmaceutical companies to develop treatments as most of its victims are too poor to buy medicines. If and when Ebola spreads to more affluent parts of the world, of course, pharmaceutical companies will adjust their research and development strategies.

As market incentives for development of treatments do not exist, it falls to governments to fund research into possible treatments and vaccines. As Marie-Paule Kieny, assistant director-general of the World Health Organization (WHO), pointed out, “If it hadn’t been for the investment of a few governments in the development of these drugs, we would be nowhere.” Much of the funding for research has come from the United States, not from humanitarian concerns for Africans, but for domestic concerns. According to a Globe and Mail article by Geoffrey York, “most of the research on Ebola treatments has been financed by the U.S. government, often because of fears that the Ebola virus could be used aesculab-stabas a form of bioterrorism.” Be that as it may, it is a relief to know that someone is working on treatment and prevention.

As the disease has occurred in Africa, you might expect that research on it should also occur in Africa with robust drug trials being conducted in an ongoing basis, Bioethicist Arthur Caplan  says it is unreasonable to expect the research to happen in Africa. He wrote, “Privileged humans were always going to be the first ones to try it. ZMapp requires a lot of refrigeration and careful handling, plus close monitoring by experienced doctors and scientists—better to try it at a big urban hospital than in rural West Africa, where no such infrastructure exists.” ZMapp is the drug given to the Americans who contracted Ebola in Africa before being flown back to the US for treatment.

It might be possible for pharmaceutical companies to build such infrastructure, but Caplan encapsulates the real reason research does not happen in Africa nicely: “Drugs based on monoclonal antibodies usually cost a lot—at least tens of thousands of dollars. This is obviously far more than poor people in poor nations can afford to pay; and a tiny company won’t enthusiastically give away its small supply of drug for free.” Enthusiastically give away? No, they won’t even develop the drug in the first place.

Now that an experimental treatment (ZMapp) does exist, should it be tested on Africans? Bioethicist George Annas says, “If the drugs we are currently working on have been shown to be reasonably safe, and if there is realistic and robust African review and individual informed, voluntary consent, use of American-developed drugs in Africa could be justified.” Annas is here emphasizing the protection of possible African research participants rather than explaining why only the privileged should receive the drug, and he has good reason.

It isn’t as though the lack of infrastructure in Africa has prevented drug trials from taking place there in the past as you might imagine from the debate over Ebola drugs. In fact, testing has raised serious issues of exploitation in the past as drugs were tested on vulnerable populations with no intention of ever providing those same populations with any treatments that might be developed. In 1994, the HIV drug, AZT (zidovudine) was found (in a study known as AIDS Clinical Trials Group 076)  to prevent transmission from HIV-positive mothers to their infants. The study was considered important in the development of drugs to treat AIDS, but there were no plans to provide AZT to the communities where it was tested once the clinical trials concluded. Research subjects in Africa bore the risks associated with taking experimental medications but would not see the benefits of the medications developed.

As there is no market incentive for pharmaceutical companies to develop treatments while protecting research subjects in vulnerable populations, it is up to governments to help promote treatments for unprofitable diseases. This has obviously happened to an extent., but we could, and should, do more. Philosopher Thomas Pogge has initiated a plan to help improve the situation. He has proposed a Health Impact Fund  that would provide a sort of artificial market incentive for companies to develop otherwise unprofitable treatments. Under the plan, governments would contribute to a fund that would then be distributed to pharmaceutical companies based on their ability to develop drugs that would have the greatest health impact. In order to receive payments from the HIF, companies would agree to provide treatments at cost anywhere in the world. I don’t know whether the Health Impact Fund will provide a solution to treating diseases that primarily affect the poor, but it certainly represents the kind of thinking required to address these serious issues.

If we are not motivated by the suffering of others in the world, and it appears many in affluent countries are not, we may do well to recognize that diseases do spread beyond all borders. Diseases that do not affect us today may well affect us tomorrow. The so-called “free” market is obviously not the solution, so we will do well to consider other options.