We agree with Mr Folkers and Dr Fauci that the success of acquired immunodeficiency syndrome research over the last two decades shows what can be achieved if enough financial and human resources are provided.Folkers GK, Fauci AS. The AIDS research model: implications for other infectious diseases of global health importance. JAMA 2001;286:458-461. FULL TEXT | PDF | MEDLINE There was serious commitment from Western governments as well as major investments from the pharmaceutical industry that anticipated a hugely profitable market in developed countries.

But many infectious diseases that continue to be the leading cause of death in poor countries do not affect industrialized countries. Without enlightened self-interest by Western governments and a profitable market for industry, drug development has ground to a virtual stand still Trouiller P, Torreele E, Olliaro P, et al. Drugs for neglected diseases: a failure of the market and a public health failure? Trop Med Int Health. 2001;6:945-951. MEDLINE: only 1% of the 1,393 new drugs approved between 1975 and 1999 are for tropical diseases,3 which account for almost 10% of the global disease burden.

Exacerbating this neglect, drug resistance is reducing the effectiveness of many available drugs. Recently, the Drugs for Neglected Disease Working Group and the Harvard School of Public Health questioned the world's top 20 pharmaceutical companies on their research and development activities for malaria, tuberculosis, sleeping sickness, Chagas disease and leishmaniasis.3 Eleven companies responded (representing $117 billion of the $406 billion world-wide pharmaceutical market.).

Of these, seven reported spending less than 1% of their research and development budget over the last fiscal year on any of the five diseases; eight spent nothing on the three most neglected diseases (ie, sleeping sickness, Chagas disease, and leishmaniasis). The public sector, increasingly focusing research along profitable avenues, is also failing. Experts estimate that annual public funding for drug research and development on these same five diseases is less than $75 million.Pécoul B, ed, Orbinski J, ed, Torreele E, ed. Fatal Imbalance: The Crisis in Research and Development for Drugs for Neglected Diseases Geneva, Switzerland: Médecins Sans Frontières/Drugs for Neglected Diseases Working Group; 2001. Available at: http://www.accessmed-msf.org. Accessibility verified November 15, 2001 Governments are ultimately responsible for ensuring that people's health needs are met.

Global liability and moral obligation must be the driving force behind research efforts. Governments could frame a compulsory research obligation that would require industry - highly profitable thanks to increasing levels of patent protectionAngell M. The pharmaceutical industryto whom is it accountable? N Engl J Med. 2000;342:19021904. MEDLINE - to reinvest a percentage of pharmaceutical sales into research and development for neglected diseases, either directly or through public programs. Such mandates, framed in a global treaty, would correct the imbalance between private sector rights and obligations under current international agreements and provide legal options to make drugs for neglected diseases global public goods.

Ultimately, not-for-profit drug development initiatives should be explored, to take drug research and development for neglected diseases out of the marketplace altogether. Nathan Ford, BSc Els Torreele, PhD Drugs for Neglected Disease Group/Médecins Sans Frontières Geneva, Switzerland