No Market: Why Some Diseases Never Get a Drug

Why some diseases get drugs and others do not, and what happens to 1.7 billion people in the gap

Between 1975 and 1999, the world approved 1,393 new drugs.

Thirteen of them were for neglected tropical diseases. Not thirteen per cent. Thirteen drugs. Slightly under one per cent of everything developed in a quarter of a century, for a category of illness that afflicts something in the order of a fifth of the human race.

It did not improve. Of the 850 new therapeutic products registered between 2000 and 2011, five were for neglected tropical diseases, and every one of those five was a new formulation or a new indication for a drug that already existed. Across twelve years, for twenty diseases affecting more than a billion people, the pharmaceutical industry produced not one new chemical entity.

This piece is about why. The answer is not a conspiracy and it is not indifference, and both of those explanations are worse than useless because they point at the wrong thing. The answer is a market operating exactly as designed, and the reason it is worth understanding precisely is that markets are built by people and can be built differently.

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What is actually being neglected

The World Health Organization classifies twenty conditions as neglected tropical diseases. Dengue. Leishmaniasis. Chagas disease. Sleeping sickness. Trachoma. River blindness. Lymphatic filariasis, which people know as elephantiasis. Snakebite envenoming. Soil-transmitted worms.

They are endemic in 149 countries. They affect more than 1.7 billion people, roughly twenty per cent of the world's population, and almost half of those affected are children. They kill more than half a million people a year, and killing is not the main thing they do, they blind, disfigure, disable, stunt, and remove people from work and school for decades.

Their combined burden is comparable to that of malaria and tuberculosis.

And the name is precise rather than rhetorical. These are not rare diseases. They are not scientifically intractable. They are neglected, a word that describes a decision rather than a difficulty.

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The money

Neglected tropical diseases receive less than two per cent of global pharmaceutical research and development investment.

Total funding for all neglected disease R&D, including HIV, tuberculosis and malaria, has plateaued at around four billion dollars a year, and the overwhelming majority of it goes to those three. In 2019, only 8.5 per cent of neglected disease R&D funding was allocated to the twenty NTDs specifically.

Go one level deeper and it gets worse. Less than five per cent of NTD research funding goes to the most neglected of them, sleeping sickness, visceral leishmaniasis, Chagas, even though more than five hundred million people are at risk from that group alone.

For most individual NTDs, annual global research spending is under one hundred million dollars. That is the total worldwide investment in understanding and treating a disease that may affect tens of millions of people. It is less than the marketing budget for a single mid-tier consumer product.

There is an old formulation for this called the 10/90 gap: roughly ten per cent of health research spending directed at ninety per cent of the global disease burden. Recent analysis suggests investment in the Big Three has shifted it statistically towards something more like 20/80. For the twenty NTDs specifically, the structural inequity has not moved.

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Why: the arithmetic, stated plainly

Here is the mechanism, and it takes one paragraph.

Developing a drug is enormously expensive and most attempts fail. A company recovers that cost by selling the successful ones at a price that covers the failures. That model requires customers who can pay.

The people who have Chagas disease cannot pay. Not because of anything about them, because they live in the places where Chagas is endemic, which are the places with the lowest incomes on earth. There is no price at which a company recovers its development costs from that population, and therefore there is no commercial reason to begin.

That is all. That is the entire explanation.

Nobody in a boardroom ever decided that people with sleeping sickness should be left to it. There was never a meeting. There is simply an investment appraisal process which asks what the expected return is, and for these diseases the answer is negative, and so the project does not start, and the absence of the project is not recorded anywhere as a decision at all.

A disease is neglected when the people who have it have no money. Every other feature of this, the funding gap, the drug counts, the pipeline, follows from that single sentence.

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The number that should end it

Now the figure that makes this genuinely maddening rather than merely sad.

Policy Cures Research analysed the returns on investment in neglected disease research: the drugs, vaccines and diagnostics brought to market over the past two decades, plus the anticipated impact of innovations expected between now and 2040.

Their estimate is that every dollar invested generates a societal and economic return of four hundred and five dollars.

Four hundred and five to one. There is no other category of expenditure available to any government on earth that returns anything remotely like it.

So why does the money not come?

Because that return is societal. It accrues to the children who go to school instead of going blind, to the economies that stop losing billions to preventable disability, to the health systems that stop treating advanced cases of things that were curable early. It does not accrue to whoever paid for the research.

The four hundred and five dollars is real. It is simply distributed among people who did not fund it, in countries that cannot invoice for it, over a timescale no quarterly report acknowledges.

That is not a market failure in the sense of the market malfunctioning. It is the market working precisely, on the inputs it is given, producing an outcome that is catastrophic and entirely predictable.

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What the industry actually does, stated fairly

A piece that stopped there would be dishonest, and this is the part most writing on the subject leaves out.

The pharmaceutical industry runs some of the largest sustained charitable operations in the history of commerce, and they are aimed at exactly these diseases.

In 1987, Merck committed to donate ivermectin for river blindness, free, in the company's own words, to everyone who needed it, for as long as it was needed. That commitment has now run for nearly four decades and has delivered billions of treatments. GSK donates albendazole for lymphatic filariasis at similar scale. Several other companies run comparable programmes, and collectively these donations reach hundreds of millions of people a year and have driven some NTDs to the edge of elimination.

This is not public relations. It is one of the genuinely admirable things any industry has done, and anyone writing about neglected diseases who omits it is not being straight with you.

But hold the distinction, because it is the whole point.

Giving away a drug you already have is not the same as developing a drug that does not exist.

Ivermectin was discovered because it was commercially interesting as a veterinary product. Its use against river blindness was a fortunate discovery about a molecule that already existed. The donation programme is magnificent, and it required no new development, and it tells you nothing about whether the industry will invest in the diseases for which no such accident has occurred.

That is why the drug-approval numbers matter more than the donation numbers. Donation redistributes what exists. Only research creates what does not.

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The strongest case against this piece

Development costs are genuinely enormous. Bringing a new drug to market, accounting for the failures, runs into the billions. Even a diagnostic, a much simpler product, costs somewhere between two and ten million dollars to develop, over years. These are not invented figures used to excuse inaction; they are what it costs.

Companies have fiduciary obligations. A publicly traded pharmaceutical company that repeatedly invested in projects with negative expected returns would be sued by its own shareholders, and correctly. The people running these firms are not free to be generous with other people's money at scale, and demanding that they be is demanding that they break the law.

And there has been real progress. The absolute number of products targeting neglected diseases has risen substantially since 2000, driven by the Gates Foundation and by the emergence of product development partnerships. Some NTDs are genuinely close to elimination. The picture in 2026 is better than the picture in 1996, and pretending otherwise would be its own kind of dishonesty.

All of that is true.

None of it explains why the mechanisms that demonstrably work remain funded at a fraction of what they could absorb.

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The part that is actually solvable

This is the reason I wanted to write this, because unlike most of what this publication covers, the solutions here are not theoretical. They exist, they have been tested, and they work.

Product development partnerships. The Drugs for Neglected Diseases initiative was founded in 2003 as a non-profit, pooling academic research, industrial chemistry and clinical capacity in the countries where the diseases actually are. It has delivered thirteen new treatments for six diseases. That is more NTD treatments from one small non-profit in two decades than the entire global pharmaceutical industry produced in the preceding quarter-century.

Let that comparison stand on its own for a moment.

Priority review vouchers. A company that develops a drug for a neglected disease receives a voucher entitling it to accelerated regulatory review of any future product, including a profitable one. The voucher is transferable and can be sold, often for a great deal of money. It converts a commercially worthless project into a commercially valuable asset without any direct subsidy.

Advance market commitments. A funder guarantees in advance to purchase a specified quantity of a product at a specified price, if it is successfully developed. This creates precisely the thing that is missing, a market, and it has been used successfully for vaccines.

And direct public and philanthropic funding, which is the least clever mechanism and the one that has produced most of what exists.

Every one of these works. Every one is currently operating below capacity. And DNDi's own fundraising director described the post-pandemic funding environment in 2025 in four words: the party is over.

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What this is really about

There is a version of this argument that treats it as a moral failing of pharmaceutical executives, and I think that version is both wrong and strategically useless.

The people running these companies are responding accurately to the incentives they operate under. If you replaced every one of them tomorrow with people of exceptional personal virtue, the drug-approval numbers would barely move, because the constraint is not their character. It is the requirement that development costs be recovered from patients, and the fact that these particular patients have no money.

Which means the question is not why won't they but why has nobody changed the inputs.

And that question has a harder answer. Priority review vouchers, advance market commitments and product development partnerships are not expensive by the standards of the states that could fund them. They are proven. The return is four hundred and five to one. The obstacle is not evidence and it is not cost.

The obstacle is that 1.7 billion people with river blindness, elephantiasis and Chagas disease do not vote in any of the countries where the decision would be made, do not appear in the polling that shapes budgets, and cannot make anyone's next quarter look better or worse.

They are not neglected because their diseases are difficult. They are neglected because neglect has no constituency.

Thirteen drugs in twenty-five years. That is not a scientific limit. It is a price signal, and price signals can be rewritten by anyone willing to write them.

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Sources

Disease burden. The figures of more than 1.7 billion people affected, endemicity in 149 countries, more than 500,000 deaths annually, and the observation that almost half of those affected are children, are drawn from World Health Organization data as cited by the Drugs for Neglected Diseases initiative and in peer-reviewed literature including Tropical Medicine and Health (2026) and the Journal of Natural Products review of natural products in NTD drug discovery. The comparison of the combined NTD burden to that of malaria and tuberculosis is from the latter.

Research funding. The finding that NTDs receive less than two per cent of pharmaceutical R&D investment is from Tropical Medicine and Health, "The pharmaceutical industry's multifaceted role in neglected tropical disease control" (2026), which also records that neglected disease R&D funding has plateaued at approximately four billion dollars annually with the majority concentrated on HIV, tuberculosis and malaria, and that the 10/90 gap has shifted statistically toward 20/80 without the structural inequity changing for NTDs specifically. The figure that only 8.5 per cent of neglected disease R&D funding in 2019 was allocated to NTDs is from the G-FINDER report as reported by DNDi. The finding that less than five per cent of NTD research funding is directed at the most neglected diseases, with more than 500 million people at risk, is from G-FINDER as cited in Drug Design, Development and Therapy. The observation that under 100 million dollars is spent annually on research for most individual NTDs is from Our World in Data, drawing on Policy Cures Research's G-FINDER project.

Drug approvals. The figures of 13 NTD drugs among 1,393 approved between 1975 and 1999, five among 850 products registered between 2000 and 2011 (all new indications or formulations rather than new chemical entities), and 66 novel NTD products entering phase I trials between 2000 and 2014 representing 1.65 per cent of 4,006 phase I trials, are from Infectious Diseases of Poverty, "Innovation in neglected tropical disease drug discovery and development."

Return on investment. The estimate that every dollar invested in neglected disease R&D generates a societal and economic return of 405 dollars is from Policy Cures Research, as reported by Devex, and reflects products brought to market over the past twenty years plus anticipated impact of innovations through 2040.

Development costs. The estimate that each new diagnostic carries development costs of between two and ten million dollars, taking account of failure, is from the Institute of Medicine's Forum on Microbial Threats.

Donation programmes. Merck's 1987 commitment to donate ivermectin for onchocerciasis to all who need it for as long as needed, and GSK's albendazole donation for lymphatic filariasis, are documented in the companies' own published commitments and in the standard literature on NTD elimination programmes.

Product development partnerships and mechanisms. DNDi's founding in 2003 and its delivery of thirteen new treatments for six diseases are from DNDi and from Devex reporting of September 2025, which also quotes DNDi's external affairs director on the post-pandemic funding environment and discusses priority review vouchers as an emerging funding avenue. The PDP model is described in Drug Design, Development and Therapy, "Drug discovery and development for neglected diseases: the DNDi model."

The piece's central analytical claim, that the shortfall in neglected disease drug development follows directly from a financing model requiring costs to be recovered from patients, that the mechanisms capable of correcting it are proven and underfunded rather than absent, and that the obstacle is the absence of a political constituency rather than either cost or evidence, is the piece's own. The facts on which it rests are in the published literature.

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