1. The World Public Health at a Crossroad Guillermo Foladori CSPO Columbia University 2003 Meeting “The Uneven Evolution of Medical Know-how” Burden Room, Low Library, Columbia University New York, 14-15 March, 2003

2. Hypothesis Health has become an expression of social struggles at world level. Some reasons are: 1. the resurgence of infectious diseases. Old and new. 2. the existence of neglected diseases from a R&D perspective 3. the declining life expectancy levels in poor countries 4. the subjective conscience developed through the struggles of NGOs and mobilized people and countries against transnational pharmaceutical industries (Pharma) and WTO These struggles and their outcomes will be an important factor in the way R& D is done and technologies are applied. They will have to do —at least— with: 1.the reductionist approach developed by Pharma 2.the subordination of R&D to charitable interests 3.limiting R&D to profitable alternatives

3. Theoretical context and conflicting reality The mistaken hypothesis of the epidemiological transition. Since the 50s developed countries went through a shift in main causes of death. From infectious diseases to cardiovascular and circulatory. So did R&D on health. But, once socio-economic and ecological context changes, so happens to diseases. Globalization brought changes: * increase of poverty, migrations, circulation of merchandises and living species *in ecosystems: urbanization in Third World and global warming * possibility of bio-terrorist actions etc. No country is free from infectious diseases

4. Pharma commands R&D Although slightly more than 50% of R&D on health is done by public institutions, the final medicine is launched to market by Pharma. This means: * 80% of the world drug market is in North America, Japan and Europe which account for only 23% of population * Only 10% of resources on R&D are oriented to 90% of the world’s burden of disease * Pharma industries are concentrated in less than 30 large multinational corporations. The sector was the most profitable in 2001. It only works where proved profits are possible. * Pharma is interested in treatment, not in cure or vaccines.

5. Recent changes in health market Aids pandemic generated large mobilizations against pharma, for lowing medicine’s prices, for producing generics, for public treatment. Pharma pressure WTO to impose TRIPS (intellectual property rights) for drugs all over the world. Many countries’ governments faced contradictions with WTO. Under pressure from civic organizations started producing generics (South Africa, Brazil, Thailandia, India, China, etc.). Nowadays the conflict is still on negotiation at WTO.

6. Public-Private Partnerships PPP PPPs are an innovative policy to reduce the 10/90 gap in R&D. Also aims to reach poor people with cheap medicine. It is the partnership of Public+Pharma+NGOs+Charitable foundations. The funds come from donations. In the last 4 years more than 80 PPPs were created PPPs are seen as the solution by Pharma, by WHO, by Charitable institutions, by government of Developed countries, by important academic sector.

7. Doubts about the working of PPPs They extend the reductionist Pharma’s approach They reinforce market driven production and distribution of medicine The participants have great differential power (Pharma or Gates vs. Zambia) Maintain high prices in developed countries Dilution of health policies in several PPPs Are not sustainable through time as depend on charitable donations Reduces technological path to those already going on

8. Final reflections The world health transition of the last decade shows that social struggle is determinant in the type and coverage of R&D and their outcomes Market oriented R&D in medicine has show its limits in satisfying social needs There is no abstract S&T exit, its benefits could be for some people at the same time that others could be neglected by the same scientific orientation